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McConnell Again on Healthcare

Mitch McConnell and the Republicans in the Senate are not satisfied with the Tom Price appointed CBO chief, who insists that there are four fingers in front of his face and apparently won’t make numbers up to help take away health insurance from 22 million people.

So Mitch McConnell and the Republicans will rely upon, and I am not making this up, “ALTERNATIVE SCORING” to further the Ted Cruz amendment to Obamacare repeal through the Senate. Republicans are expecting it will take weeks to get the scoring from the CBO.”

Repubs are running out of time to repeal the ACA and achieve tax reform under reconciliation. The budget year ends EOM September. If the ACA is not repealed by then, it has to wait until next budget year. You can not do two reconciliations in one year and the other one is tax reform.

McConnell To Use Alternative Scoring for Healthcare Bill, Crooks and Liars, Frances Langum, July 13, 2017

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three bad ideas which I think would be political winners for Democrats

Matthew Yglesias commands,
I obey. Now I just have to come up with three bad ideas.

1) $25 minimum wage. I am not sure about the $15 dollar proposal. I’m pretty sure that $25 would be too high. I guess it would be popular too.

2) Protection that’s what you’re here for . I am sure that total protectionism is a bad idea, and hinting at it worked pretty well for Trump.

3) Eliminate all taxes on the lower 99%.

I tend to wonder if maybe this isn’t such a bad idea, but I suspect that it would imply either huge deficits, undesireable cuts to Federal spending, or taxes on the top 1% which are higher than optimal.

In any case, I am rock solid certain that many Republicans are sure that Democrats are soon going to propose this and win all future elections. They wouldn’t argue against class warfare in the complete absense of any class warfare (except for theirs on behalf of the rich) if they weren’t terrified.

4) I would say health care reform with coverage of pre-existing conditions, gauranteed issue, Community rating and no mandate (to promise all the nice things without the necessary costs and destroy the individual insurance market entirely) except that Obama has already done that (the Barack Hussein Obama Jr was elected president of the USA, so don’t even think of tyring to tell me that bad policy is bad politics).

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California’s Single Payer Plan

Reader EM put this comment up in the AB open thread. I thought it was interesting enough to place on AB as I also wonder about the question being asked and the answer; “can a state divert Medicare funds to support a state single payer system?” The simple answer is “no,” Medicare funds can not be allocated to states and the same holds true for VA funding for healthcare and the tax credit to companies for healthcare insurance. Congress would have to approve it in new legislation. David Dayan discusses this issue of California Single Payer starting at minute 31 David Dayen on CA’s SIngle-Payer Debacle on Politics and Reality Radio. This is in direct answer to EM’s question.

Furthermore for Medicaid and CHIPS a 1332 wavier for state contributions must be deficit neutral and not create a deficit in the Federal Program which is required for CHIP and Medicaid. I assume a similar wavier for Medicare fund diversion would also have to be deficit neutral so as not to cause harm to overall Medicare.

The state of California is one of the top 10 states in income (median income 9th). If a state such as California pulls out of Medicare, who makes up the difference in funding? There are other states such as McConnell’s Kentucky who rank in the bottom 10 with the lowest income (median income 46th) and a higher percentage of people living in poverty.

Here is EM’s dilemma:

Mother Jones, Kevin Drum, June 29, 2017 12:38 PM; “I Get Letters

The single biggest proponent of SB562, California’s single-payer health care bill, is the California Nurses Association. But here’s something I didn’t know until yesterday: the CNA is aggressively using support for SB562 as a litmus test for being a true progressive. The bill is basically unpassable, but it’s being used as a way of whipping up the Bernie wing of the Democratic Party against traitors who fail to support it.

Apparently this applies even to B-list bloggers. I got an email today from Chuck Idelson, Communications Director for CNA’s umbrella organization, National Nurses United. Here is how it ended:

“Having seen two years of your hatred for Bernie Sanders, it’s not surprising you would be equally hostile to ideas he champions like single payer, but it would be nice if you were a little more honest with your readers, or maybe you can recommend the name of your magazine be changed from Mother Jones – who actually fought for working people – to Milton Friedman, which would better reflect your class sympathies.”

It is good to see that progressive organizations are learning communications skills from the Trump administration. But, I wonder if this kind of attitude is helpful in attracting and maintaining support for progressive causes?

POSTSCRIPT: “Just for the record, I have supported single-payer health care for at least the past 25 years. But for a variety of reasons, it needs to be done at the national level. No state has ever been able to make it work.”

EM: Still trying to find answers to this Cal single payer thing in terms of financing.

New Republic, Clio Chang, June 30, 2017, “ What Killed Single Payer in California?

“A legislative analysis found that California’s single-payer plan would cost $400 billion to implement, $200 billion of which would be new spending. Critics were quick to point out that this “hefty” price tag is twice the state budget. Furthermore, the bill did not include a funding plan (although the bill’s language ensured that Healthy California would not launch unless it was funded).

However, a report by professors at the University of Massachusetts Amherst, commissioned in part by National Nurses United, estimated that after taking in the savings of single-payer, such as lower administrative costs and prices of pharmaceuticals, the actual cost of the plan would end up at around $331 billion. And, because 70 percent of the state’s current health care spending is covered by public programs like Medicare and Medi-Cal, California would only need to come up with $106 billion in new revenue, which researchers proposed could be done through two new taxes (a 2.3 percent gross receipts and sales tax), with exemptions for small businesses and tax credits to offset costs for low-income families. In exchange, nearly all of Californians’ medical expenses would be covered, doing away with premiums, copays, and deductibles . . .

But according to the Affordable Care Act’s Innovation Waiver, if a state comes up with a credible alternative to the ACA, the federal government is obligated to provide the funding. Pollin said that while it is impossible to know in advance what the Trump administration will do, “you can also pass the bill, and obviously it has to be contingent on us continuing to get 70 percent of funding that we now get.” Pollin felt that Rendon’s objections were technical ones — they need to be addressed, but don’t raise any issues that can’t be worked through. “The concerns that they raised were pretty narrow. Nobody said this is crazy, we can’t do this,” he said.

There are problems other than the fact that the bill did not include a specific funding mechanism. The biggest hurdle may be Proposition 98, a complicated California funding law that requires that around 40 percent of the state’s budget go to schools. This means that a huge portion of any increase in the state budget would have to go to education, so legislators would have to come up with almost double the money to cover the single-payer plan. To get around this, voters would have to first pass a ballot initiative.”

EM: I cannot find anything at all in the ACA’s Innovation Waiver that says Medicare funds can be used.

FamiliesUSA,Cheryl Fish-Parcham, January, 2016 “ What Advocates Should Know about 1332 State Innovation Waivers

“The 1332 waivers apply only to private health insurance coverage and the marketplace, not to public programs like Medicare or Medicaid. But states can seek multiple waivers from HHS at the same time. For example, they might ask permission to change their Medicaid programs under an 1115 waiver and their marketplace coverage under a 1332 waiver. However, the federal government will evaluate each type of waiver separately – an 1115 waiver must still meet all of the existing standards for Medicaid 1115 waivers, and a 1332 waiver must meet the requirements we describe below. How Could a 1332 Waiver Affect Medicaid or CHIP?

EM: I cannot believe there is anything in Medicare law that would allow such a transfer, and it does not appear to me there is anything in the ACA that even mentions using Medicare funds.

Perhaps someone in here has more knowledge than I have been able to find, but I see no purpose whatsoever in this financing plan from Pollin that relies on funds that cannot be accessed. All this thing does is confuse the issue.

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Senate healthcare bill costs 15 million their health insurance next year, 22 million by 2026

One consequence of electing the popular vote loser is that the official winners act as if they have a mandate for the most extreme version of their policies. Thus, we have proposed legislation, the misleadingly titled Better Care Reconciliation Act, that will not only roll back Obamacare’s expansion of Medicaid, but impose further large cuts on the program in addition. In total, the Medicaid cuts will come to $772 billion through 2026.

As a result primarily of ending the individual mandate, the Congressional Budget Office (CBO) estimates that 15 million fewer people will be insured in 2018 than would be the case with current law. As healthier people remove themselves from the individual market, this will cause increases in insurance premiums and the likelihood of further collapse of the market. As Tierney Sneed points out, there will be some premium reductions in the individual market, but this will be due to the plans being much less generous and having higher out-of-pocket costs. Tellingly, the CBO report judges that low-income people will not buy insurance under these circumstances. As a result, by 2026 there will be 22 million fewer people without insurance.

On the revenue side, of course, the Republican bill cuts taxes on the rich by $541 billion.

It’s hard to know where to begin. The chutzpah of such a gigantic transfer from the poor to the rich staggers the imagination. As with everything surrounding Trump, this is completely surreal.

The good news is that it’s not a done deal. Three Republican Senators (Collins, Paul, and Heller), one more than McConnell can afford to lose, are currently opposed to the bill in the Senate. Republican governors who have expanded Medicaid (Sandoval of Nevada and Kasich of Ohio), plus Baker of Massachusetts (which expanded Medicaid under former Governor Deval Patrick) have also come out against the bill.

It’s no secret, then, what to do. Keep the pressure on your Republican Senators. If there is no vote this week, you’ll have the opportunity to see them over the July 4th recess as well. The stakes have never been higher.

Cross-posted from Middle Class Political Economist.

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Senate AHCA Version – Premium Increases and Subsidy Reductions

CBPP has this pictorial analysis of the increased premiums resulting from the Senate version of the AHCA for a 60 year old at 350% FPL with an ACA Silver plan. “For a 60-year-old with income of 350 percent of the poverty level (about $42 ,000 today) facing the average premium on HealthCare.gov, out-of-pocket premiums would jump by an estimated $4,994. Premiums would rise by $ 2,022 for a 45-year-old at this income level, and fall by $75 for a 30-year-old. Premiums would rise by $2,694 for a 60-year old with income of 300 percent of the poverty line, and by $1,903 for a 60-year old with income of 150 percent of the poverty line.”

Premium Increase The Senate AHCA Bill increases Premium Costs .

A sixty year old slightly above 350% FPL would face the loss of thousands of dollars in tax credits. Presently, the ACA covers up to 400% FPL and limits how much can be charged for age to 300%. The AHCA goes to 500% and reduces the subsidy coverage to 350% FPL.

Losses in Tax Credits Senate AHCA eliminates subsidies (difference between total cost of the plan and a percentage of income) for those between 350% and 400% FPL resulting in $thousand of dollars in cost for those in the Individuals Market. Tax-credit subsidies would cover only 58 percent of health care costs, rather than 70 percent as under current law a decrease in actuarial value. People in higher healthcare cost states would have to pay more as depicted in the CBPP chart.

Under either Republican Plan, higher premiums and deductibles would force people into lower level plans covering less at greater cost. Why do this and incite anger amongst constituents when you can just keep on doing what you have done in the past and undermine the ACA with blocking the Risk Corridor program and cut deductible subsidies by killing the CSR? I believe McConnell is thinking along these lines and can shift the blame of the resulting ACA failure to Dems. Dems would take the blame as no one would understand how it came to be and little would be explained by the press.

Senate Bill Still Cuts Tax Credits, Increases Premiums and Deductibles for Marketplace Consumers CBPP, Aviva Aron-Dine and Tara Straw, June 25, 2017

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Chait vs Roy on Baicker not really vs Baicker

Jon Chait has a brilliantly ruthless takedown of the absurd defences of the AHCA (house obamacare replacement) and BCRA (Senate version) . His main point is that Republicans are lying claimiing the huge cuts to Medicaid aren’t cuts to Medicaid and that the huge increase in the number of uninsured will actually be zero.

He also criticizes Avik Roy. This quarrel has become very interesting. Roy praised the BRCA. He refused to answer when Chait asked if he had also written it. Roy will not say if he is commenting on his own work without noting the conflict of interest.

Jonathan Chait‏Verified account @jonathanchait
Update: @avik tells me his policy is to not disclose his role in crafting legislation.

Chait notes that Roy praises the bill for increasing deductibles and also notes that Republicans denounced the Obamacare deductibles — for being too high. This just shows hypocrisy ( ok psychopathic dishonesty) or GOP politiicians. I’m sure Roy believes dedcutibles should be high, and Republicans in Congress have revealed a preference for high deductibles.

Chait also objects to Roy’s claim that Medicaid doesn’t cause improved health. Interestingly I had the same debate with someone on twitter yesterday. In both debates, the case against Medicaid is based on a citation of Baicker et al (2013) the report on the Oregon Medicaid experiment.

Chait (and I) responded by citing Somers Gawande and Baicker (2017) who wrote

Insurance coverage increases access to care and improves a wide range of health outcomes. Arguing that health insurance coverage doesn’t improve health is simply
inconsistent with the evidence.

and

One head-to-head quasi-experimental study of Medicaid versus private insurance, based on Arkansas’s decision to use ACA dollars
to buy private coverage for low-income adults, found minimal differences.11

So is it Chait’s experts against Roy’s experts ?

Not at all. Roy bases his argument on Baicker et al and Chait on al et Baicker. Katherine Baicker PhD (who should know) does not think that Baicker et al (2013) showed that Medicaid doesn’t work.

Indeed she concedes much less than Chait does. He wrote “The study was unable to detect better physical health outcomes.” This is false. The study found better physical health outcomes in the treatment group than in the control group. What Chait should have written was “the study was unable to detect statistically signficicantly better physical health outcomes”.

Treating a statistically insignificant evidence improvement as evidence that there was no improvement is a gross error. It is also almost universal (I have doubts only about the “almost”). In fact Baicker et al found statistically significant effects on access to health care, diagnosis of diabetes, and treatment of diabetes. They did not find new proof that standard treatment of diabetes is better than no treatement. In every other context, this is not treated as an open question. The study did not find statistically signficant evidence that the benefit was smaller than predicted based on other studies either.

But the motto of the New England Journal (and all serious scientific journals) is first make no claims which go beyond the data.

Statistically insignificant is not an assertion. It doesn’t mean zero. It doesn’t mean small. So it is always favored. Then it is read as meaning small or zero.

Chait understands this. He argues that the Baicker et al (2013) study had low power so the fact that “The study was unable to detect better physical health outcomes.” [failed to reject the null of zero effect on physical health] doesn’t tell us much. But even in the context of a discussion of power, he refuses to distinguish zero from statistically insignificantly different from zero. I think there is some rule that people writing for general audiences must not use technical terms like “statistically insignificant”. The result is that they write falsehoods.

Tens of thousands of people a year may die partly because people just will not accept that the Neyman Pierson framework is what it is.

In any case, Roy is reduced to arguing that he understand Baicker et al (2013) and Baicker doesn’t. He is not in great shape totally aside from the question about unreported conflicts of interest.

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BCRA CBO Score

WASHINGTON (AP) — Congressional Budget Office sees 22 million more uninsured by 2026 under Senate health bill.

Toher Spiro appears to be snipping and tweeting the key bits of the CBO report

Premiums for a 64-year old with middle income go from $6,800 under ACA to $20,500 under BCRA

Deductibles for plans eligible for tax credits go from $3,600 under ACA to $6,000 under BCRA

death spiral

open thread.

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Welfare Reform Kills ?

This is an update of this post in which I expressed immense confidence that welfare reform killed people in Florida .

The post is based on
https://www.ncbi.nlm.nih.gov/pubmed/23733981

Muennig P1, Rosen Z, Wilde ET. (2013) “Welfare programs that target workforce participation may negatively affect mortality.”

Abstract

During the 1990s reforms to the US welfare system introduced new time limits on people’s eligibility to receive public assistance. These limits were developed to encourage welfare recipients to seek employment. Little is known about how such social policy programs may have affected participants’ health. We explored whether the Florida Family Transition Program randomized trial, a welfare reform experiment, led to long-term changes in mortality among participants. The Florida program included a 24-36-month time limit for welfare participation, intensive job training, and placement assistance. We linked 3,224 participants from the experiment to 17-18 years of prospective mortality follow-up data and found that participants in the program experienced a 16 percent higher mortality rate than recipients of traditional welfare. If our results are generalizable to national welfare reform efforts, they raise questions about whether the cost savings associated with welfare reform justify the additional loss of life.

It’s not in the abstract, but they also analysed a larger data set and got a larger point estimate of 26% higher deaths due to participation in welfare reform.

The authors have since conceded that they unreasonably underesimated the standard errors of their point estimate. They used cluster robust standard errors with only 2 clusters (2 counties). This is not valid (the estimate of the variance of the point estimate of 16% more deaths is biased down). A reader noticed (as I should have) that the large difference between 16% and 26% would be extremely unlikely if the analysis had been correct.

using a reasonable fixed effects estimator (without the cluster robust consistent but biased down standard errors) they get

In the article we also presented combined results including participants in both Escambia and Alachua Counties, again controlling for year of birth, year of assignment, and site location and clustering the standard errors on location. The point estimate for that analysis is 1.26 (95 percent CI: 1.10, 1.45). Without clustering the standard errors around location, while controlling for location fixed effects as well as the other covariates, the new point estimate is 1.26 (95 percent CI: 0.96, 1.66).

So the more reasonably estimated stardard errors are roughly twice as large as the biased down ones. This means that the null of no effect (ratio of mortality rates =1) isn’t rejected at the 5% level. It is close. But the p-level of a t-statistic of a bit less than 4 is tiny (hugely significant).

The corrected standard errors imply evidence that welfare reform killed people, but not strong evidence. Hence the question mark in the updated title.

Like the authors, I apologize. I should have read the paper more carefully.

I thank Douglas Hess @douglasrhess for pointing out the published correction

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Did Conway Con Herself

This is remarkable even for the Trump administration. Kellyanne Conway claimed that the Medicaid slashing BCRA proposed by the gang of 13 doesn’t include “cuts to Medicaid”.

The Trump administration position appears to be that Trump could sign it in to law and keep his promise to protect Medicaid from cuts. Wow.

I am not President of the USA, but this doesn’t seem to be good strategy to me. It makes it clearer than ever that Trump will throw representatives and senators who vote yes under the bus if the horrible bill becomes even more unpopular as a horrible law causing horrible suffering. It also makes it clear that they will have to deal with the debate about whether $ 800 billion is zero. They could choose to repeatedly say that Trump is a liar (which will hurt them as much as voting no) repeatedly tell blatant lies about the suffering they caused, or they can avoid that debate by voting the bill down. To me the third option looks very attractive.

Already Susan Collins has had to say that she “disagrees” with Conway. She should understand that a yes vote will only be the beginning of dignity wraithdom.

It’s a small thing compared to tens of thousands of deaths a year, but Senators don’t like to be humiliated at all. I hope this makes some difference.

Update: Also Price

“HHS Secretary Tom Price making a bold delararion to @DanaBashCNN: “We would not have individuals lose coverage.” “

We know he’s shameless, but how many seantors representatives are willing to stand up for such absurd lies.

Also I don’t think insulting the CBO is optimal strategy right now. For one thing they are working very hard over the weekend to get a report which the Senate needs in order to consier the BRCRA. If someone treated me as Price treats them, I would be very very lazy (trivially true as I am, have always been and will always be very lazy). Also they can calculate effects on coverage outside the 10 year window first (they are doing this) and work backwards.

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McConnell’s AHCA Kabuki

he McConnell Obamacare repeal and replace “discussion draft” is worse than I imagined possible even taking into account that it would be worse than I imagined possible. I fear he made sure it was horrible so moderate Senators could win staged battles and claim they had saved people (needless to say I am not the first to write of this possibility).

I guess a vox explainer is always useful and Sarah Kliff is very smart thorough and reliable.

The bill is surprisingly aweful in two ways. First it doesn’t slow the phasing out of the ACA Medicaid expansion over 7 years but rather does it in 3 (from 2021 through 2024). Several relatively non reactionary Republican senators stressed how important of 7 year phaseout was to them. Also the bill contains no additional funding to deal with the opioid addiction crisis. Many of those senators specifically proposed this increased funding.

I fear that this is all theater. That the so called moderates will get their 7 years and their opioid treatment funding and then vote yes. Not including them in the “discussion draf” will make this more dramatic, allow the self described moderates to claim credit, and give them cover.

The Senators in question are almost saying this is their price.
I will include phone numbers in case any reader is interested in calling to say he or she is not falling for it. All are from the very useful
https://www.trumpcaretoolkit.org/

The Senators include
Robert Portman of Ohio (202-224-3353) who wrote
portman

This almost explicitly says his price is an extended Medicaid phaseout and, especially, money for treatment of opioid addiction.

Shelley Moore Capito of West Virginia (202-224-6472 called senator Capito with the accent on the a not on the i as in the Italian word for understood)
She has a very strong position on increased opioid treatment funding. West Virginia (like Ohio) is hard hit by the epidemic.

Her web page includes

Earlier today, I posted a link to the health care discussion draft on my website for all West Virginians to read. Over the course of the next several days, I will review the draft legislation released this morning, using several factors to evaluate whether it provides access to affordable health care for West Virginians, including those on the Medicaid expansion and those struggling with drug addiction.

Which, again, is very clear. I want to mention that I guessed there was a press release similar to Portman’s before checking, and why, lo and behold, there is (it’s almost as if they coordinated).

Dean Heller of Nevada (202-224-6244 is another self described moderate (and up for election in 2018 and very vulnerable)

His web page has

“Throughout the health care debate, I have made clear that I want to make sure the rug is not pulled out from under Nevada or the more than 200,000 Nevadans who received insurance for the first time under Medicaid expansion. At first glance, I have serious concerns about the bill’s impact on the Nevadans who depend on Medicaid. I will read it, share it with Governor Sandoval, and continue to listen to Nevadans to determine the bill’s impact on our state. I will also post it to my website so that any Nevadans who wish to review it can do so. As I have consistently stated, if the bill is good for Nevada, I’ll vote for it and if it’s not – I won’t.”

Again quite clear. The phrase “the rug is not pulled” is almost explicit that slowly sliding it out from under them would be OK. The reference to Sandoval is important, as Sandoval is very popular in Nevada and signed a letter opposing the House AHCA and generally arguing for bipartisan compromise (so did Gov. Kasich of Ohio whom Portman didn’t mention).

update 3: This is interesting. John Ralston is a very highly respected expert on Nevadan politics. He tweeted

“I don’t think so. And will say he [Heller] votes No after consulting with @GovSandoval.”
replying to another top reporter, Ronald Brownstein, who tweeted “#AHCA reduces # covered by Medicaid in NV by 45%. #SenateHealthCareBill proposes > l/t cuts. Can @SenDeanHeller vote Y? @RalstonReports”
end update:

OK how about Lisa Murkowski (202-224-6665 only interested in voice mail from Alaskans) ?
Nothing yet. I actually find this promising. She might not have decided on the price of her vote.

Finally (for moderates for now) Susan Collins of Maine (202-224-2523) Nothing on the McConnell discussion draft yet. A lot on the Opioid crisis (very bad in Maine too). Also “bipartisan” is her favorite word. Actually the web page section on health looks OK. Her voting record doesn’t. Collins and Murkowski strongly support funding for Planned Parenthood. Neither have said they will vote no if the elimination of that funding stays in the bill (most likely they propose an amendment and it goes down 50-51 including Pence). I do not want to count on Senator Collins growing a spine.

update: Collins spoke with the press instead of having a staffer write a press release. Her comments as reported by Tierney Sneed are mildly interesting

Sen. Susan Collins (R-ME) gave the Senate health care bill released Thursday a mixed review, but zeroed in on its major cuts to Medicaid as a potential problem for her.

She took issue with how the Senate bill, starting in 2025, used a rate of growth for federal funding for Medicaid that is significantly slower than the typical increases of costs for the program.

“I’m very concerned about the inflator that would be used in the out years for the Medicaid program,” she told reporters in the Capitol a few hours after the bill was released. “It’s lower than the cost of medical inflation and would translate into literally billions of dollars of cuts.”

She added that she was concerned about how the cuts would negatively affect rural hospitals or prompt states to restrict Medicaid eligibility.

This might amount to something. Unlike “pulling the rug out” Heller, Collins is talking about the long term and a huge amount of money. The ceiling on Medicaid spending amounts to a huge cut over 10 years. It is they key measure used to finance the bill’s tax cuts for the rich. Unlike the 3 year Medicaid extension phase out it can’t be fudged. The case for Heller, Capito, Portman Kabuki is strongly supported by the fact that they don’t specifically address the ceiling.

It is vital that people who had no problem before the ACA understand that they will have huge problems if the AHCA passes, because of the huge cuts of legacy (pre-ACA-expansion) Medicaid spending. The fact that Collins discusses this would be a hint that she might actually vote no (if she weren’t actually Senator Susan Collins (R-Maine) who always always caves).

end update:

update 2: Collins is stealing the stage. I think she is torturing us. She said she can’t vote for a bill which deprives tens of millions of health insurance (I’ll believe she can’t if she votes no and not before)


ehd update 2:

Separately 4 right wing Senators said the McConnell draft is too close to the ACA: Ted Cruz, Mike Lee, Ron Johnson (Wisconsin) and Rand Paul (Kentucky).

I think Paul might really mean it. He is extreme and resistent to party discipline. Also the ACA has benefited Kentucky enormously. Blocking the repeal bill would be good for Rand Paul (and Mitch McConnell). Blocking it for not being extreme enough could be crazy like a fox 11- dimensional Aqua Buddha chess.

Ron Johnson has been hinting a no for a long time. He was just re-elected. Here I think that senators with 6 safe years might be more likely to vote no. Failure to pass a bill with hurt Republicans in the short run. Passing a horrible bill will hurt them in the long run.

I’m pretty sure Cruz and Lee are play acting. My guess is that they said no to establish a bargaining position — if McConnell is the right most position, the bill will move further left than if they pretend they might vote no. I read somewhere thatCruz had an individual statement in which he made it almost clear he was going to get to yes.

Summing up, I have no prediction for how this will end. But I do very strongly suspect that Heller, Capito and Portman will win two (staged) battles and get 7 year phaseout and some opioid money, declare victory and vote yes.

update 4: My prediction was wrong (as usual). Heller denounced the bill. He described many of its horrible aspects, definitely including the long term cuts to legacy Medicaid. This is not an issue which can be fudged, because the amount of money involved is huge. He still might cave, but it would be an authentic cave not a staged victory. This is very good news. Also there is even better news reported by The Washington Post

Sen. Dean Heller (R-Nev.) announced that he could not vote for the legislation without revisions, singling out the measure’s long-term spending cuts to Medicaid as the reason for his opposition. The announcement caught some Republicans in Senate Majority Leader Mitch McConnell’s orbit by surprise.

If McConnell had been counting on Heller, his count could be off. In particular, he might have counted to 49 and assumed he could get one more from a senator unwilling to decide the victory for the Democrats. Heller’s announcement takes pressure off of her (she is named Lisa or Susan).

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