The Rust Belt Is Burning: Republicans Lay Waste to their Base on Health Reform

William Tecumseh Sherman, who laid waste to the South at the end of the Civil War, famously said, “War is Hell”.  So, too, is health reform.  And like Sherman’s infamous March to the Sea, where he burned town after Confederate town, the Republican War on Obamacare entered its attrition phase with the introduction on Monday in the House legislation to repeal and replace ObamaCare.  Except that Ryan is marching in the wrong direction; his troops are marching “north” and burning towns behind their own lines.

Ryan’s bill released Monday was greeted with a chorus of derision from the newly empowered Republican base; some conservative wags dubbed the bill “RINOCare”. Thoughtful conservative analysts savaged it.  Michael Cannon, the hard core libertarian Cato Institute health analyst, called it “a trainwreck waiting to happen” and suggested  that “ it will create the potential for the sort of wave election Democrats experienced in 2008”    In Reason.com, Peter Sunderman wrote,  “it’s not clear what problems this particular bill would actually solve.”

Ryan’s draft neither repeals nor replaces ObamaCare.  

It retains the insurance underwriting rules that have raised the cost of health insurance, as well as ObamaCare’s 10 million person Medicaid expansion (until 2020).  And then, it shrinks Medicaid only by attrition, protecting the enhanced federal match for the expansion population. 

It leaves the exchange system intact, removing the individual mandate and  replacing the income-related premium subsidies with an age-related system of refundable tax credits tilted toward younger people. The refundable tax credits are a much  better mechanism that the complex and difficult to administer premium subsidies, but they are way too small to help lower income and older people stay insured.   Many millions of families will return to the ranks of the uninsured.

It also doesn’t effectively stabilize the individual insurance market. While Ryan’s  bill creates a $100 billion slush fund for states to protect the individual market, that they might use for high risk pools or other purposes, it accentuates the risk selection problem by letting the potentially sick enter the market with only a 30% premium penalty for a year. 

Robert Laszewski, a fierce critic of ObamaCare, argued that this sum of money wouldn’t come close to dealing with either the Obamacare individual health insurance market problems or the gap that gutting Medicaid would create.” He went on to argue that

“Obamacare is so poorly constructed it is literally an anti-selection machine. The Republican proposal is worse.”  Mario Molina, whose Molina Healthcare sells coverage on nine ObamaCare exchanges, said, You’re going to see big rate increases, and you’re going to see insurers exit markets.”

The bill also doesn’t reduce federal spending or costly regulatory mandates enough to matter to Republican “deficit hawks”.  Though it has yet to get a CBO score, it is highly likely that the bill  increases the federal deficit, which will be unacceptable to the large fiscal conservative wing of the Congressional Republicans.

But worst of all, it lays waste to President Trump’s electoral base– Baby Boom vintage working class white voters in Appalachia and the Rust belt. As many as 5-7 million of whom got coverage from ObamaCare.  The median age of a Trump voter is 57, and they came from counties with serious underlying health problems.   

These working class Trump voters get clobbered by Ryan’s bill.

The AARP, which advocates for older folks said:  This bill would weaken Medicare’s fiscal sustainability, dramatically increase health care costs for Americans aged 50-64 and put at risk the health care of millions of children and adults with disabilities, and poor seniors who depend on the Medicaid program for long-term services and supports and other benefits.”

Thanks to the switch from income related premium subsidies to a fixed and not terribly generous refundable tax credit, 60 year old workers all across “Trump Country” earning $20 thousand a year (thus ineligible for Medicaid)  take between a 50-75% haircut on federal help that will push millions of them out of health coverage, according to a Kaiser Family Foundation analysis

What Ryan’s bill DOES do is repeal $600 billion in taxes on the wealthy, as well as pharmaceutical companies, health insurers and health manufacturers. It also lifts the $500 thousand annual cap on deductibility of health insurance executive salaries imposed by ObamaCare. And it spends a remarkable six pages making ABSOLUTELY CERTAIN that winners of high dollar state lotteries will NOT receive Medicaid benefits!

If Trump had run on Ryan’s plan- cut taxes for the rich and throw millions of working class people back into the raging sea of no health coverage- he would never have been elected President in the first place. If the bill is enacted, Trump’s promises to “cover everybody” and provide people “something terrific”- better coverage for less out of pocket cost- will look as specious as President Obama’s campaign promises about cutting family costs by $2500 a year and “if you like your health plan, you can keep it”. “TerrifiCare” this bill isn’t.

Trump is now in a very difficult position. Even if he pushes hard, it is unlikely that this bill, as written, gets the 50 Republican votes he needs to clear the Senate. If he pushes hard and loses, his ability to enact the vital tax cuts and infrastructure plans equity markets and businesses expect will be impaired, and the economic problems he promised to address will not be solved.

It is not clear that Trump has the political leeway to cancel the Medicaid expansion without damaging the political fortunes of the sixteen Republicans who expanded their programs. And his staff clearly has no grasp of the magnitude of change required to reverse the meltdown underway in the individual insurance market, nor the votes in the Senate to change the key elements of ObamaCare that have led to that meltdown.

What Trump’s colleagues in the House have done with Ryan’s bill , unwittingly, is set fire to their own government. As pollster Sean Trende demonstrated in his masterful electoral analysis, The Lost Majority  the wave elections of 2006, 2008 and 2010 were “illusory” realignments of American political power.

What the wild swings in these elections-from Republicans to Democrats and back to Republicans in three successive seasons- showed was an increasing disconnect between the day-to-day reality of American voters and their political elites. Trende’s analysis foreshadowed Trump’s surprise victory.

Trump understood that disconnect better than any other actor on the 2016 electoral stage, and connected with a lot of hopeless, dispossessed and angry voters. Unless he can turn his generals around and stop setting fire to his own people, his reign, to paraphrase Hobbes, will be nasty, brutish and short.

Jeff Goldsmith is an associate professor at the University of Virginia and National Advisor, Navigant Healthcare. 

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  1. Viable answers to your question might stand a better chance of emerging if patients and practicing physicians were part of the reform process.

  2. ““Provider” is a gigantic dogpile”

    That is right, but within the ACA there is use of that term and that involves physicians. That invalidates your argument against Bob McNutt, just above.

    “Physicians … and generate something like 70% of the health system’s costs.”

    Of course physicians generate a huge amount of the costs. They are the ones doing almost all the diagnosis and treatment which is what healthcare is all about.

    I don’t think any of us know the intimate workings of Tom Price or anyone else you might mention. What we know is that the ACA failed, third party payer failed, Medicare keeps costing more, the VA is sickening and Medicaid is inadequate yet the one’s at fault for these debacles want to pretend that they have the answers. They are failures and are not to be trusted.

  3. “Provider” is a gigantic dogpile which includes the Cleveland Clinic, your local massage therapist, pharmacists, neurosurgeons, acupuncturists, pet therapists, home health aides and a ton of other folks.The term is virtually meaningless.

    Physicians are and remain the core of our health system; they are the “deciders” and generate something like 70% of the health system’s costs.
    Continue to feel their virtual absence in this is telling.

    Also, have you noticed the near complete absence of the Trump admin’s senior doc, Tom Price, in all this stuff? He and Tom Pence, who ran (and expanded) the Medicaid program in Indiana, are the two logical co-ordinators of the Administration’s positions on this stuff. Pence and Price seem pencilled in as “salespersons”, not shot callers.

    Instead, we have a former Congressman from South Carolina, now OMB director, with almost no domain knowledge, a former CEO of Goldman Sachs (ditto) and a former mid level DHHS staffer calling the shots.

    Lotsa luck, guys.

  4. That is the problem with those that think they have the answers. The word physician never has to be mentioned for the law to be devastating to the physician. By the way with all your said erudition didn’t you know physicians are frequently referred to as providers? The are 625 entries under the word provider alone.

  5. Not sure that this will surprise you but the only mention of the word “physician” in the entire AHCA is in reference to needing a physician to certify that an abortion is necessary to protect the life of the mother. That’s it.

  6. Correction to above.

    “In years past the subscibers of Medicare paid their doctors and were reimbursed a fixed sum.”

    Then Medicare changed the rules supposedly to save money. Today the government pays the doctor in most cases. Costs have climbed and the doctor started to respond more to code numbers than the patient.

    That I think means that you believe Medicare made a mistake since you seem to be suggesting that the physician (and other providers) not be directly reimbursed.

  7. “As I read the Ryan plan, the existing subsidies will continue for 2018 and 2019.”

    Hummm, I wonder if the congressional election cycle has anything to do with that.

  8. “It is very hard for me to understand why some people say the Affordable Care Act is a failure. The policy was intended to reduce the number of people who had no healthcare insurance ”

    Placing people on Medicaid is not a solution nor is making it so that costs are so high to some that their insurance is worthless.

    The other problem with your thesis is that healthcare insurance is not healthcare. ACA insurance is merely permission to wait on line, be told how your healthcare will be provided and to pay ever increasing costs.

    Finally, the ACA is unsustainable.

  9. Saurabh, if you want progress in an industry you cannot have government setting their prices. Ultimately research and development is dependent upon the capital markets. People invest, not in drugs, but in the best return of their capital perhaps with an intention of spreading their risk.

    Our policies are creating high drug prices so you can decide to cut prices and the production of drugs will change. Maybe the capital markets will shift money into the Woody Allen orbs so that we can feel even better about our stupidity.

  10. “What if we required CMS and insurers to pay directly to subscribers rather than to providers? ”

    Jim, that is a fine idea. As stated by Anish, many people here along with the policy makers were instrumental in the passage of the ACA so how can we trust them? We can’t because they follow the same logic they have been following for 50 plus years of failure. They blame the poor results on everyone else not supporting their beliefs because they don’t recognize human self interest and think the state can alter that basic thing common to all or almost all humans, especially Americans.

    No matter which way these failed makers of policy turn they either have to depend upon force or the free marketplace. They often choose the former. Mandates, fines, penalties, jail, rules, regulations, etc. That is not a good way to protect our Liberty.

    In years past the subscibers of Medicare paid their doctors and were reimbursed a fixed sum. Did that cure the ills of Medicare? No, but it increased costs tremendously . Those costs are being paid by our young families who cannot even educate their own children properly. Both parents are working and those same makers of policy have taught them to depend upon the government to bring up their children.

  11. Barry, you note that up to 40 million people will get tax credits averaging $3,000 each.

    But in the Ryan plan, unlike the Cassidy-Sessions plan, the tax credits will only be activated if someone uses them to buy a plan. A lot of people in the Ryan plan will be too discouraged to use their tax credits, so the expense to the gov’t will not be $120 billon.
    Small comfort, though.

    As I read the Ryan plan, the existing subsidies will continue for 2018 and 2019. People will assumedly not have to face the scrawnier tax credits until 2020. Out of sight, out of mind for some.

    The Republican stalwarts will probably assert that the tax credits are being paid for with Medicaid reductions.

    The Ryan crew is so desperate to get out a bill, that they are ignoring the warning signs of carrier withdrawal from the market altogether. Robert Lascewski has done a fine job of pointing out that carriers cannot lose hundreds of millions every year.

  12. Thank you for letting me be part of this discussion. I am no expert, for sure, just a doc who gets ill, like all people do. The rust belt I see burning is the pocket books of patients who are ill.

    I was glad to see comments raising issues about the veracity of the attacks. As I got my fixed income Starbucks coffee this AM, I read the NYT article saying medical groups are aligning against the Republican bill. Having been part of teams trying to introduce bills and introducing one of my own, I learned the following.

    Those who align against have a special interest. If medical care groups are against, this means it likely is a good bill.
    Yesterday the NYT put out top salaries; look how many in top 10 have to do with medical care (physicians at the top).
    Those that think that medical care is anywhere where it could be for people are lost.
    If you think we have a government that is interested in us, just look who is on the governing board of CMS.
    If we continue to think that medicine should be a high cost ponzi scheme and insurance must support, nothing will change.
    The goal of all insurance plans should be equality; none of the present ideas embrace that fully enough. When we do this, however, docs and hospitals salaries will plummet.
    I repeat, if medical care systems are against, this is a good bill.

    There are miles to go before any of this matters. In the mean time, useless tests, treatments are being propagated via specialty guidelines daily to keep the beat going on. I remain convinced, talking and consulting with patients about informed choices, that the only solution is to let patients decide the value of our services

  13. Runaway cost is what it’s always been about. If that weren’t so, we wouldn’t be agonizing nearly as much about finding a way to provide access for everyone in America regardless of means (something every civilized nation should do).

    What if we required CMS and insurers to pay directly to subscribers rather than to providers? The payments could be based on some fact-based standard of “fair” reimbursement (I know…but ya gotta try) which are gently reduced over time. Then people getting care would be highly incented to shop for it and act like true consumers with the usual impacts seen in other markets. Of course, we need transparency of cost, quality and outcomes so that they have the ability to shop, but finally the consumer demand would be there. As Joe tells us, we see this phenomenon in uncovered services such as lasix and cosmetic. The history of paying directly to providers was one most likely led by Blues which, back in the day, were provider dominated, and it was touted as a convenience to subscribers (which, in a way, it was, if you can remember how we kept receipts in a “shoebox” for major medical). In addition to pure fee for service, isn’t this one of the big reasons our costs are out of control?

  14. To be clear, Hayward, I said Obamacare failed to address the costs (I’m assuming I’m one of the “some people”). And, no I’m not a policy wonk – just a practicing physician.

    It failed by maintaining the ban on CMS from negotiating prices with pharma (something I’m sure CMS is not gagging to do) because of pharma’s $$ donation which, in India and Italy, is called bribing but I believe you have a delightful term for this – “lobbying.”

    It failed by virtually ignoring the elephant in the room, what drove people to bankruptcy – the exorbitant, and insensate, hospital charges inflicted on the uninsured, underinsured and those with high deductibles.

    Instead it inflicted a regulatory blitzkrieg on doctors, the worst of whom to suffer, are the ones looking after Medicaid patients.

    I’m amazed the sensitivity Obamacare induces. If this is the best the Americans can produce, I worry about the future.

  15. They would probably say it’s a failure because health insurance premiums are higher than expected due mainly to adverse selection and networks are narrower than expected which means a lot of people lost their doctors when president Obama promised them they could keep their doctors if they liked them. Moreover, over half the people who got health insurance because of the ACA got expanded Medicaid as opposed to an exchange plan that they chose. The penalty for remaining uninsured was way too weak which resulted in too many healthy people choosing to remain uninsured.

    While you are correct that the ACA did nothing specific or consequential to attack healthcare costs, Medicare costs slowed considerably since 2009 and are only up about 3% for the first five months of fiscal 2017 and are essentially flat on a per capita basis. This good news is probably independent of or in spite of the ACA but it’s welcome news nonetheless.

  16. It is very hard for me to understand why some people say the Affordable Care Act is a failure. The policy was intended to reduce the number of people who had no healthcare insurance and, in that regard, it worked as demonstrated by the fact that we now have 20 million people insured who previously were not. The ACA was not designed to drive down the cost of healthcare, as we really didn’t (and still do not) know how to do that. Clearly the cost of healthcare is now rising for ACA plan. Health insurance rates are also rising for commercial insurance plans which are unrelated to the ACA, thus attributing the rise in healthcare spending to ACA would appear to me to be an unjustified conclusion.

    Assuming one agrees with the above facts, I would appreciate hearing from a policy wonk why they believe ACA is a failure.

  17. I would be delighted with 125% of Medicare as a replacement for chargemaster rates, especially for care that must be delivered under emergency conditions and price shopping is, by definition, impossible. Hospitals keep claiming that Medicare rates don’t cover their fully allocated costs, especially for outpatient services, tests and procedures. 125% of Medicare should be sufficient. CMS should also move to site neutral payment and pay no more to physician practices owned by hospital systems than independent docs get for the same work.

  18. Well said! My instinct is the more our non practicing policy wonks wring their hands or proclaim that disaster is imminent the more I am inclined to think there must be something good about it….and that more control is going to get down to the doctor and patient level.

  19. The reality is that any replacement of Obamacare is going to be just as bad as Obamacare. There is no Pareto optimal healthcare policy – someone, somewhere is going to get shafted, instead of someone else, somewhere else. I wish I could drill this into the cerebral cortices of both liberals and conservatives, both of whom reside in some Disneyland world where there are no trade-offs, just Minnie Mouse and solutions.

    The only thing the Republicans can do, which the Obama administration made a dog’s dinner out of, is to control the costs inflicted on patients. They can ban, yes ban, the exorbitant chargemaster prices hospitals charge and say they can charge no more than Medicare rates (this simple solution is worth a thousand pages of statutes in Obamacare); negotiate prices with pharma, which CMS is too frightened to do because it’ll place the responsibility of saying “no” on them, and no one in the US likes responsibility; abolish the regulatory burden on doctors who look after poor people.

    Healthcare has been over intellectualized by people who spend their time over intellectualizing. For foreigners like me, who spent our childhood admiring the US for sending men to the moon, the predicament you find yourself in healthcare begs incredulity. Control the costs and sanity will return, slowly.

  20. It is very hard as a physician to translate policy when it comes out to what it looks like when implemented. There was a time when health care policy experts had credibility with folks like me. This was the basis for me voting for the ACA twice. The reality of the ACA and its constructs were a failure of gigantic proportions. Yes a narrow band of the populace benefited.. but it exposed a wide gap between the policy experts and the niran’s and Koka’s of the world. The response of the policy folks to our protestations was to ignore us and double down on prior
    Policies like P4P , ACOs.. that just fail at the ground level as implemented.

    I struggle to understand how this bill translates to practice. As an example, less money to a Medicaid program does not necessarily mean less care if the $$ are used to give Niran a $100/month for each Medicaid patient for all of their outpt care.

    Perhaps this bill is as disastrous as is said. You’ll excuse my skepticism about how this bill will work coming from folks that got it pretty wrong for the last 8 years.

  21. Uwe, I am touched by your confidence that Donald Trump will turn into a reader once he writes his memoir. According to Trump’s co-author on “Art of the Deal,” Tony Schwartz, Trump barely had the attention span to answer a few questions about his life, much less read what Schwartz wrote — much less read anything else. To read The New Yorker interview with Schwartz from July, 2016 today, when Donald Trump has become President Trump, is truly terrifying. (Albeit likely less terrifying than the IRS audits and law enforcement scrutiny to which Schwartz will now be subjected for 8 years.)

    Although I’m sure that when Trump does become a reader, reading the Congressional Record and the Federal Register will be among his first choices.

  22. Assuming roughly 40 million people who don’t currently get health insurance through an employer, Medicare or Medicaid and a median age of about 40, it will cost $120 billion per year to provide an age-based tax credit averaging $3,000 per year to each of them. If we want to establish high risk pools for the sickest people so most of the rest of this population can buy health insurance for a significantly lower premium, it could easily cost another $100 billion or more to cover them less whatever they can afford to pay in premiums out of pocket. Throw in additional subsidies for lower income people who make too much to qualify for Medicaid and need family coverage and it will take a lot of money that has to be paid for somehow by someone to square this circle. This will be a big problem for republicans who never met a tax increase they can tolerate or accept. Keeping the ACA tax hikes already on the books would at least be a start but not enough to get health reform right in my opinion.

  23. “poor people just don’t want health care and aren’t going to take care of themselves.”

    Said by Rep. Dr. Roger Marshall. This typifies the Repugs, “Let them eat cake” attitude to health care “Replace”.

  24. “I wish for a kind of health care reform that treats patients and physicians with fairness and respect.”

    Yes, but who will pay?

  25. Just keeping the ACA taxes, especially on higher income people, which includes myself, would provide a lot more flexibility in how to structure health insurance reform without increasing the federal deficit. The biggest single challenge will be financing high risk pools that actually work for the people who need them. The next biggest challenge will be providing subsidies on top of age-based tax credits to ensure that nobody pays more than 10% of modified adjusted gross income out of pocket for health insurance premiums and much less than that for people with low incomes but too much to qualify for Medicaid.

    There is a disconnect between allowing insurers to charge older people five times more than younger people for health insurance premiums but only providing an age-based tax credit worth twice as much. It should be five times as much. Shouldn’t it?

  26. Look to Trump to claim credit for “Repeal”, but blame Democrats for no ‘Replace”.

  27. Don’t forget the policy priority of vindicating tanning salon owners.

  28. Patients and physicians seem to be the only key stakeholders in the health care sector with no leverage on reform. I’m not sure if burned out physicians would risk leaving Medicare, Medicaid, and commercial networks to salvage some semblance of career satisfaction. Staying boxed in may be preferred over the risk of being locked out. Physician cooperation with reform goals is an externality that’s hard to read.

    Physician burnout affects care quality by eroding motivation, self-esteem, sense of fulfillment, work-life balance, and much more. Should disgruntled doctors wish to mount a mass exodus, I can imagine legislators making it illegal to do so, which would only compound the growing sense among physicians that reform is a license to gang-rape the medical profession. That’s strong language. But if we water it down by calling physician burnout an unintended consequence of reform, it feels no less painful to the doctors and patients affected.

    A sense of professional malaise has by now found its way into most medical settings. Careers and lives are at stake. I wish reform policies would pay attention to cultivating the human resources that play such a key role in producing the outcomes, satisfaction, and efficiencies that are needed to create a functional health care system. I wish for a kind of health care reform that treats patients and physicians with fairness and respect.

  29. Excellent piece. Thanks Jeff! On so many levels, AHCA fails. And for many different groups. I’d note the “job lock” issue – for more well off people in 50s and 60s. With almost all the major health care interest groups opposing the initial draft, it’s not likely it can pass…in the House let alone the Senate. We’ll see how open the Rs are to substantial changes. Paul Ryan thought it was “his day” on all these fundamental changes, especially Medicaid. Probably not. And Trump does not have the political capital to make a difference; he doesn’t have any credibility on the details of the issue, either.

  30. Thanks for the serious response. The majority of the points I agree with, especially re cost and waste as the key, though perhaps disagree with the most expeditious way to address those items.

  31. Half does seem ambitious. But yes, there are ways that require discipline and political will, something in short supply. We first need complete price, quality, and outcomes data to use to create consumerism (whether it’s individuals, employers, CMS, or insurers). Competition is not today at the right level (amongst providers of care) and not on the right things (said price, quality, and outcomes). Waste accounts for perhaps $1 Trillion a year. Can’t be eliminated entirely, but maybe halved? Changing how we pay for care that incents lower rates of use. Addressing chronic illness that accounts for arguably 2/3 of all claims expense. Changing the insurance model to cover more of less (i.e., the unpredictable, more catastrophic) rather than things that are not insurable events at all under normal insurance definitions. Strong mandates that everyone have insurance, as we do in many states for auto. [I know it’s pricier]. The list goes on. The point, without being facetious, is that this mess is all about our runaway costs, and we are truly rearranging the deck chairs with current efforts. We can do better.

  32. “without halving the cost of care, we’re sunk”
    Oh, simple, just cut the cost of care in half! I’m sure if you can just give Trump/Price a hint on how to jump that little hurdle all will be great! Pardon my facetious tone, but seriously, are there suggestions on how to do this without imposing a national draft of all docs, nurses and hospital administrators and nationalizing all hospitals and pharma companies? (there I go again!, I can’t stop myself from being facetious!).

  33. President Trump yesterday announced that he is proud to support the American Health Care Plan as now drafted. For immigrants like me, still struggling with the English language, this is good, because we now know what the word “terrific” connotes in English.

    I suspect that when he writes his memoirs, then ex-President Trump will actually read the bill. Of course, he could also read Jeff’s post – NOW.

    I view the AHCA as Phase I of a series of policy measures shafting the forgotten middle class. Wait until you see the tax-reform bill. A clue can be had from an analysis of Trumps tax reform proposal of October 2016, performed by the Tax Policy Institute of the Urban Institute, a highly respected group of analysts.


    To be sure, this seems to be a static rather than a dynamic analysis (i.e., assuming no response of real variables, e.g. work effort or investments in capital equipment, to the tax cut). But dynamic analyses usually suffer from the GIGO phenomenon – what comes out of them depends very much on what response parameters (so as not to be understood we economists call them “elasticities”) are fed into the simulation model. This approach allows economists great flexibility, shall we say, to serve their partisan clients’ preferences. Concretely, does anyone sincerely believe that the Heritage Foundation and the Center for American Progress would produce the same results from a dynamic analysis of a tax-cut proposal?

  34. Yup. Disaster II. What will be interesting is what happens in my home state of Massachusetts. Charlie Baker, who DOES understand coverage, is trying to shore up the individual and corporate mandates, and tidying up what was Romneycare. However, the loss of Medicaid dollars (perhaps, given the very recent waiver approval MA received) would hurt. Joe Flower (today I think) posted a well written letter to a Trump advisor, basically saying that without halving the cost of care, we’re sunk. Well done both Jeff and Joe). But, critiquing what’s going in is a tad like shooting fish in a barrel.

  35. This makes sense to me, Uwe. But right under the resentment of those immediately below is hopelessness and a loss of a sense of purpose. We have stranded tens of millions of working class Americans and disinvested in the communities where they live. You and I have visited many of these places in our journeys. We will shortly learn if Trump was serious about helping them. Someone needs to, and without patronizing or condescending to them, or we will have much more serious political problems down the road. . .

  36. AS much as I want to tell Trump supporters “I told you so”, I think we should just regard this as coming out so Trump can make it look like he did something quickly. I suspect, hope, this is not that close to a final bill.


  37. Jeff, I think you nailed it.

    Ross seems to be arguing that the “poor-ish” older white voters, in their joy at sticking it to the truly poor, will not notice the knife in their own back. That’s anybody’s guess, but here’s mine: They will notice it, a lot. It is striking how much of the Trumpian base in all these interviews and analyses after the election were not just in deep ignorance about Obamacare vs. the ACA vs. Kentucky Kynect or whatever version of exchanges they used themselves. They were often in flat-out denial that Trump and the Republican Congress they had given him would take away the healthcare that they had gained in the last few years. I remember quotes like, “Oh they wouldn’t do that. That wouldn’t make much sense.” And they trusted Trump’s vague but sweeping promises.

    Ryan and Company acknowledge as much by stretching out the phase-in over years (in the case of Medicaid, beyond the 2018 elections), hoping that it won’t hit the voters all at once when they suddenly find that they are off the Medicaid program, and individual insurance rates have shot up, and these poor folk are left with a promise that a year in the future they will get a check for a quarter of what they have paid for a super-high-deductible narrow-network plan that does them little good.

    This is a very concrete in-your-pocket issue for people. I think Trump’s base (and the Congressional Republican’s base) is now and soon will be getting some tough and rapid wall-to-wall education.

  38. via email

    There’s an excellent article in Today’s (Wed) NYT showing very much the opposite.

    Title: Budget Blueprint Reflecting Resentments Against the Poor. It explains why the poor-ish poorly educated whites so resent the poor and the welfare benefits that the poor receive, that they support Trump. Yes, I agree Trump’s policies will be also horrific for the white poor-ish also (possibly worse), but reality is not a major factor in these policy wars.

  39. No one translates complexity as well as Jeff Goldsmith. In this case he called
    out the entire Republican/Repeal/Replace community on health policy reform
    and gave us a surprisingly accurate insight into why Trump is President. Because
    Republicans sold out their constituencies on the most costly issue in American
    politics and policy. Yeah Jeff.

  40. I agree, that yuge number, MILLIONS OF THEM, lottery winners are bleeding us dry.! (gawd, you can’t make this stuff up)

  41. The most important thing is to stick it to those damn lottery winners who are cheating and staying on Medicaid. The second most important thing is for piolicy wonks to argue if that section is 10% of the bill or 5% based on whether you count the first 60 pages or the supplement too