Political Animal Blog

A Grand Health Care Bargain: Let States Kill the Exchanges, but Add Public Options

After President Trump hilariously blamed the failure of Trumpcare on the Democrats, no one but his most fervent supporters took it seriously. He and Paul Ryan never even tried to garner Democratic support to repeal Obamacare; nor did they have any right to expect Democrats to help repeal the first program ever passed to provide near universal health coverage. But then Trump said this: “when they come to make a deal,” he’ll be receptive. It could be total bullshit, but if Trump is genuinely willing to embrace an approach that’s not dependent on the Freedom Caucus (his new Worst Friends Forever), a very good grand bargain actually is possible.

To see the shape of one possible deal, one must start by understanding the Democrats’ actual views about Obamacare (as opposed to the caricatures fed by conservative media and politicians for seven years).

Democrats were divided in 2009 between those who wanted a single-payer system and those willing to accept more of a market-based approach, in which most insurance would still be provided by private companies. Obama pushed for the latter, based on Mitt Romney’s system in Massachusetts.

So while Democrats like many things about Obamacare, they don’t actually have a deep allegiance to the state exchanges, which have ended up as the most problematic part of the system. Democrats have defended them because right now they’re the only solution for the individual insurance market.

But Democrats should be willing to throw the state exchanges overboard for the right deal. Here’s an idea: let states kill the exchanges, but add a robust “public option” tied to Medicaid, Medicare or the Veterans Administration health system.

The concept of the public option has evolved. During the 2009 legislative process, progressives pushed hard for a provision allowing government-run insurance plans to be offered in the state exchanges. This, they argued, would help the exchanges work better by providing a fall-back plan in counties where there were too few private insurance plans. And they viewed it as a step toward a single payer system. But conservative Democrats balked and the provision died.

In the 2016 presidential campaign, a new kind of public option was born. In response to Bernie Sanders’ advocacy of “Medicare for All”—a single-payer system run through the Medicare program—Hillary Clinton proposed a “Medicare buy in” plan.  Under her plan, people between the ages of fifty and sixty-five would be able to “buy in” to Medicare, paying discounted premiums and getting the Medicare benefit system.

In the days since Trumpcare’s failure, some Democrats have revived the idea of Medicare for All. As an opening gambit for bargaining, the idea makes some sense. But in addition to it being politically impossible right now, Medicare for All would be devilishly hard to make work and would likely spark immense political opposition not only from Republicans but from seniors jealous of sharing their “earned” benefits with others who haven’t paid into the system as they have.

A more plausible idea comes from an unlikely source: Christopher Ruddy, the publisher of the ultra-right-wing site NewsMax and a big Trump pal. Ruddy suggests that Trump give up on dealing with the conservative Republicans (since they don’t want universal coverage) and instead strike a bipartisan deal in which “an upgraded Medicaid system” would “become the country’s blanket insurer for the uninsured.” Ruddy doesn’t cast it as a buy-in, but it’s pretty close, since he wants to remove the income requirement on Medicaid, which currently is limited to the poor. He notes that Medicaid is actually better than Medicare at containing costs. Indeed, some of the most encouraging experiments—in terms of lowering costs and improving health outcomes—have come with Medicaid dollars. And because Medicaid is seen as insurance for the poor, rather than the elderly, opening a buy-in option for it is unlikely to trigger the same kind of political blowback from seniors.

A third government program that ought to be part of a deal is VA health care. As Phil Longman and others have noted in this magazine for more than a decade, the VA provides as good or better care at lower cost than virtually any other health care system in the country. That’s true today, despite all the (mostly false) horror stories we’ve been told about veterans dying as a result of long waits for doctor appointments. The VA has actually been far more successful than fee-for-service Medicare at containing costs and encouraging outcome-based medicine.

What if we combined these ideas?

First, require that states allow anyone to buy into Medicaid, with premiums tied to income.

Second, make all veterans, not just those with service-related medical conditions, eligible for VA care, and allow their spouses and children to buy into it as well. Politically, veterans’ groups would probably welcome this idea, because it would shore up demand for veterans’ facilities that is currently declining along the number of veterans.

Third, do as Clinton suggested and let Americans aged fifty and older buy into Medicare. (Over the long-term, Medicare itself needs to be reformed as a way of controlling overall medical cost inflation, but that’s for another day.)

With these options available, states could choose to shut down their state exchanges if they want. They could eliminate benefit requirements for the private insurance in the individual market. Let a wider variety of low-budget plans to proliferate as Republicans have advocated. If they’re not adequate people would have the safety net of being able to get government financed health care.

In truth, these three government programs are quite different. Over time, we’d develop a sense of which of the public models—Medicare, Medicaid or VA—works best. We would be able to compare their track records in terms of not only coverage and costs, but also health outcomes. The system could evolve in the direction of one of those approaches, or could result in a hybrid that combines private insurance with a robust public option.

But since it would be voluntary, no person would have to choose “government run health care.” Indeed, the private sector would be liberated to provide health insurance with less interference. As part of a deal, Democrats could allow for more selling of insurance across state lines (something the Obama administration was open to in some forms) and medical malpractice reform (which Obama had also expressed a willingness to negotiate on in exchange for something truly substantial).

In other words, Republicans can get a less regulated private insurance market in exchange for there being a powerful public option.

I’m obviously dramatically oversimplifying the particulars of what Trump called “the little shit,” i.e., how the systems actually work.  But the elements of a grand bargain are there.

One other possible advantage: it would drain some toxins from the health care debate. Conservative who hate government involvement in health care are free to choose private plans. Others would be free to try the government-backed approach. Yes, over time there would be debates about whether to expand one approach or the other. But the choices would be mostly made by consumers, not politicians.

Dark Rhode: The Effort to Silence Sen. Sheldon Whitehouse

It’s obvious why they want him gone.

If you watched last week’s Senate confirmation hearings for unqualified Supreme Court nominee Neil Gorsuch, you saw just how effective Senator Sheldon Whitehouse (D-RI) can be when it comes to challenging right-wing ideology. Gorsuch was intellectually overpowered by Whitehouse, a former US Attorney and state Attorney General.

Whitehouse is arguably the right’s biggest nuisance. Conservatives cannot stand his criticism of the special interests responsible for destroying democracy in the United States in the seven years since the Citizens United decision. They cannot stand his condemnation of the fossil fuel industry on the Senate floor, and his full-throated call for the return of bipartisan action on climate change. They cannot stand his strict scrutiny of the Trump administration.

If the Senate changes hands in the 2018 midterm elections, Whitehouse will have a more prominent platform to tear apart conservative claptrap. As David Bernstein noted last year, had Democrats won the Senate in 2016, Whitehouse would have likely become chair of the Committee on Environment and Public Works, currently in the clutches of arch-denier John Barrasso (R-WY). Whitehouse as EPW chair would be a nightmare for Carbon Inc.–a nightmare the fossil-fuel industry and its allied interests would rather avoid.

You may recall Marlon Brando’s line from Apocalypse Now, referring to Martin Sheen’s character as an “errand boy, sent by grocery clerks, to collect a bill.” It looks like right-wingers may have found their errand boy to go after Whitehouse next year:

[State Representative] Robert “Bobby” Nardolillo has decided to wait until May to publicly announce whether he is running for the U.S. Senate against the two-term Democratic incumbent, Sheldon Whitehouse.

On March 2, Nardolillo filed a statement of candidacy for the U.S. Senate with the Federal Elections Commission. The filing positioned him to start raising money toward a potential 2018 run for the seat Whitehouse has held since ousting then-Republican Lincoln D. Chafee in the November 2006 election. Nardolillo’s campaign committee name: “Bobby 4 Senate.”

Nardolillo’s Republican allies anticipated an announcement this coming Monday in his hometown of Coventry.

But Nardolillo, a 37-year-old funeral director, told The Journal on Monday: “This is an extremely important day for me. I really want my parents to be in attendance. They don’t return home from [Florida] until May. So, I’m [going to do] some work with my team and fundraising.”

Nardolillo shouldn’t have any problem raising money, considering the large number of polluters and plutocrats in this country who want rid of Whitehouse. Anyone who thinks New England Republicans are less reactionary than Republicans in other parts of the country may want to reconsider:

One of only 11 Republicans in the 75-member Rhode Island House of Representatives, Nardolillo has made “illegal immigration” one of his signature issues.

He is currently seeking support from the Democrat-dominated House for a resolution urging Congress to change federal law to allow proof of citizenship as a requirement for registering to vote.

Other Nardolillo bills seek to resurrect former Republican Gov. Donald Carcieri’s “E-Verify” executive order. One would require the state to use the federal government’s E-Verify program to electronically verify the validity of social security numbers “to ensure that all employees of the executive department are legally eligible to be employed in the United States.” Another would require sheriffs to verify the immigration status of every incarcerated person brought into court, and notify federal immigration officials of anyone “lacking legal immigration status.”

Of course, Nardolillo believes “Whitehouse spends too much time talking about climate change and not enough about the economy.” That the economy will be severely impacted by human-caused climate change seems to be lost on this fellow. However, that doesn’t necessarily mean he will lose.

Much like John Kingston’s likely challenge to Massachusetts Senator Elizabeth Warren, this is a race that progressives would be well-advised not to ignore. In a post-Citizens United world, one cannot take the outcome of any Senate race for granted. Don’t underestimate Big Oil’s desire to finally shut Whitehouse up and force him out of the Senate. Don’t underestimate Nardolillo’s ability to demagogue his way into a competitive contest, especially with millions of dollars in dark money serving as a megaphone for his malicious message. Don’t underestimate, for one second, the importance of this race.

Trump’s Reality Distortion Field is Shattering

Greg Sargent at the Washington Post has long been making the case that Trump’s main communications strategy is to assault the notion of shared objective reality itself. In Trumpworld, the only arbiter of crowd sizes or climate science or wiretapping is Donald Trump himself, and everything else is “fake news” regardless of what facts might invalidate his narrative.

And for a while, it was working. During the presidential campaign, Trump lied with reckless abandon but never seemed to suffer for it. That’s partly because his opponent also suffered from perceived credibility issues, but it’s mostly because the news media treats presidential elections like a game where any claim is in bounds as long as a candidate can get people to believe it. And because Trump is the sort of figure it’s hard to take one’s eyes off of, his tweets and pronouncement manage to derail news cycles and capture attention. It was thought that perhaps we were entering a new political era in which reality simply no longer mattered.

But campaigns are one thing. Governing is another. And Trump’s reality distortion field is failing him now that he has to grapple with something more than campaign coverage.

Sargent himself noted this fact almost a week ago, referencing reports that Trump’s tweets were no longer having the narrative-driving force they once did. But the failure of the Republican health plan has cemented the degree to which Trump is losing his ability to gaslight and confuse enough people to get his way.

Donald Trump has always carefully crafted the image of a tough guy negotiator, through ghostwritten books and reality TV show characters. But it’s not wholly clear that Trump has ever had more than a few tricks up his sleeve: bully people with money and influence, play hardball, pretend to refuse offers, and when all else fails swamp the opposition with attorneys. It’s not exactly a creative arsenal, and Trump wouldn’t have had it available to him in his business career without a lot of inherited wealth and strings pulled on his behalf.

But when he attempted to play those games with the Republican Congress, they simply laughed in his face. When he attempted similar gambits against the federal judiciary over his travel bans, the judges simply used his own words against him.

Now his tweets do less to drive national narratives in his favor than they do to cause him embarrassment and scandal, whether it’s promoting a Fox News show or claiming to be wiretapped by his predecessor.

The reality distortion field is breaking, and people are becoming immune to Trump’s simplistic mind games. Without them, it’s not clear what Trump has left. He’s certainly no policy expert, and he doesn’t have the relationships on Capitol Hill to sustain him. It must be miserable for him.

But then, reality does have a way of reasserting itself.

Trump’s Provocation-Based Foreign Policy is Dangerous

Today brings news that Donald Trump literally gave German chancellor Angela Merkel a $300 billion bill for NATO expenses last weekend:

Donald Trump handed the German chancellor Angela Merkel a bill — thought to be for more than £300bn — for money her country “owed” Nato for defending it when they met last weekend, German government sources have revealed.

The bill — handed over during private talks in Washington — was described as “outrageous” by one German minister.

“The concept behind putting out such demands is to intimidate the other side, but the chancellor took it calmly and will not respond to such provocations,” the minister said.

Never mind that this isn’t how NATO funding works. The gall of leveling such a juvenile stunt on a much-needed ally is appalling. But it’s not the first time. Trump has spent his presidency insulting a host of allied countries from Mexico to Australia to China to Sweden to Britain and others. And that doesn’t even mention potentially hostile powers like China and the countries included on his travel ban.

Of course, the only country that Trump explicitly declines to insult is Russia. Nor is it an accident that Trump seems so upset at funding an alliance designed to help European allies keep Russian military threats at bay. Beyond darker conspiratorial possibilities, Trump sees in Putin’s right-wing, authoritarian, explicitly nationalist, anti-globalist religious conservative leadership a natural ally for him, while he sees Europe as part of the problem. They can’t say it publicly, but Bannon and Trump see Russian oligarchs not just as potentially helpful hackers and destabilizers, but kindred political spirits. Nor is it an accident that both Trump and Putin engage in foreign policy by provocation.

The difference is that while Russia in its position of weakness and yearning for territorial expansion stands to gain from destabilizing the world order, the United States stands to lose. But Trump and Bannon don’t understand that. As racist nationalists, they see America as the victim of a world that takes advantage of trade deals to send away jobs, and allows immigration to dilute the racial and cultural purity of white western states.

Nor do Trump and Bannon seem to understand the consequences of their actions. They think it’s funny to throw their weight around and make demands, but as with their failure in negotiation with the Freedom Caucus over healthcare, they don’t seem to understand the weakness of their negotiating position.

For now, the world simply doesn’t take them seriously. Merkel can laugh off this stunt without a second’s thought.

But future incidents of provocation like this could lead to war. If Trump treats North Korea with the same insouciant aggression that he treats Germany, it could lead to a nuclear holocaust in Seoul or Tokyo.

But maybe Trump and Bannon don’t care. After all, it mostly wouldn’t hurt white people on American soil, right?