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Healthcare Insurance History

run75441: I have been fortunate to run across incredibly intelligent people here and other places who continue to impress me with their command on particular topics. Esmensetoo has an excellent knowledge of healthcare and healthcare insurance and how it has evolved. I was not expecting quite this much. It does cover all of the bases and there is still more to be had. I hope you enjoy reading it as much as I did.

In the 1980s when managed care was just coming into being in a substantial way, I worked with every major insurer in my region — Blue Cross, Blue Shield, Group Health (a Kaiser-type care provider that is now, in fact, owned by Kaiser), as a marketing professional. I also worked with several major regional health care providers, including the Sisters of Providence, who were the founders of the first hospitals in our region in the mid-19th Century. In the 80s they were trying, under the new deregulated environment, to create a health insurance vehicle too — that would use their hospital network. Ultimately, they were never able to worked out the details of a plan that both met what they saw as their responsibilities to the community and thought would be financially viable.

By the end of the 80s the late-1970s and later deregulation that led to “managed care” also encouraged insurers, at that time that primarily meant Blue Cross and Blue Shield, that had been founded as non-profits and had operated as such for all of their history, to become for profit (earning those in the executive suites HUGE paydays. It) was also bringing a lot of questionable new for-profit insurers into the health insurance market — many were little more than scams; adopting all the questionable practices we are all later became too familiar with — for instance, finding all kinds of clever ways to deny coverage when premium payers became ill. Also, as “managed care” which was supposed to control the cost of premiums and care that had started inflating in the 70s drove non profit insurance out of the market premiums began to really soar while what and who was covered was becoming more restricted. Small businesses started dropping insurance for workers and large insurers started offering lesser benefits at higher cost.

By the early 90s people were demanding reform, again. (Which, in my opinion, played an important role in Clinton’s election — and then the Democrats failure to pass anything in his first 2 years, along with other things like the bank scandal, contributed to their loss of the congressional majority for the first time in 40 years).

In my state, Washington, demand for reform was a really big issue for almost everyone, certainly including me. In 1992 I went to work for a local Democratic political consulting firm that was running the campaign of a reform candidate for Insurance Commissioner. She ran on setting standards to keep the scammers out of the state, setting up a system of state support for low cost insurance for the employees of small businesses, and developing community clinics that would treat people on a sliding scale. The insurance companies of course pushed back and demanded things that compromised her vision. But she still got most of what she ran on done. We ended up with system that was far from perfect but that did, did keep the scammers out of the market and the community clinics were an important resource. But the state supported small business insurance had too much paperwork and was especially unworkable for people whose work hours varied from quarter to quarter — which is common for low wage workers. And, unfortunately, by the time Obamacare passed, with similar reforms in terms of what insurers were required to provide, we only had one insurer left in the state who was offering Individual Insurance. It was excellent insurance but very expensive.

Thanks to those reforms we were in a good position for an easy transition to the ACA. We had a little technical difficulty right out the gate (embarrassing for state that sees itself as a tech leader) but mostly the transition was painless. The nonsense the Republicans and Trump have been indulging in has created problems though.

This is already too long — so I have no time to back up these three points but here are 4 things that many misunderstand about the history of our health care system that makes it difficult to have intelligent conversation about reform:

1. Our health care system was not created by the “free market.” Americans traditionally saw health care as a community responsibility. Community taxes, in addition to charity, and at times some non-profit insurance-like schemes, were used to help support community hospitals from colonial days on, often these hospitals were associated with religious denominations or orders but not always.

2. The Federal government also was involved in health care AND insurance very early — creating a hospital system for seaman in the late 18th century and requiring those using the system to purchase insurance to help cover the cost of care. In the 19th century that Marine Hospital Service also began to support medical research. The NIH, which has been very important in both funding research and doing research, was created out of the Marine Hospital Service.

3. Health insurance was not created by the “free market’ either. IT IS NOT RISK INSURANCE — and the commercial insurance industry avoided it like the plague for most of our history because they understood that it wa sn’t risk insurance but rather a way of socializing costs — and that it was unlikely to be profitable (while actually insuring care). Health insurance was created by the hospital industry and it was non-profit until “reformers ” de-regulateded it in order to make it easier for insurers to profit by choosing who and what would be covered and what providers would be paid (something, obviously, the AMA objected to).

4. The connection between employment and insurance was not created by FDR. From the very beginning hospitals identified employment groups — people who, like the seaman, and like the loggers in my state that the Sisters of Providence provided with a crude-insurance plan — $1 a month would insure they would have care in the very likely case that they were injure d — while allowing the Sisters to provide care to the poor too. Illness and injury deprived people of their ability to work and earn. So it made sense to ask the employed, especially those in dangerous occupations — to pay something while they were well and earning, so there would be resources available to care for them when they were not.

by run75441 (Bill H)

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Preventive Drugs in the Last Year of Life

I had thought these types of treatment had gone by the wayside in treatment during the last year of life. According to an Medscape article they have not.

“‘Physicians should carefully consider whether the prescribed drugs are likely to achieve their benefit within the patient’s remaining lifetime,’ the authors concluded. The study included 151,201 patients ages 65 years and older who died in Sweden at a mean age of 81.3 years from 2007 to 2013. ‘The use and cost of preventive drugs during the last 12 months of life were the main study outcomes.’ The drugs of ‘questionable benefit’ assessed in the current study included antidiabetic drugs, antihypertensives, statins, and bisphosphonates medications for the treatment of chronic anemia and vitamin and mineral supplements.’

Receipt of these long term preventative drugs added 20% to the cost of treatment during the final year of life. ‘The median drug cost during the last year of life was $1,482 (interquartile range $700-$2,896).'”

By run75441 (Bill H)

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Seema Verma Spends $Millions of Taxpayer Funds Trying to Improve Her Reputation

Spoiler: It isn’t working. Charles Gaba at ACA Signups had this up.

In an excellent scoop by Dan Diamond and Adam Cancryn this morning, Politico reports CMS Administrator Seema Verma, the person in charge of Medicare/Medicaid and who takes great joy in trashing Medicare and Medicaid, has spent millions of dollars on partisan consulting firms to boost her image.

The Trump appointee who oversees Medicare, Medicaid and Obamacare quietly directed millions of taxpayer dollars in contracts to Republican communications consultants during her tenure atop the agency and including hiring one well-connected GOP media adviser to bolster her public profile.

The communications subcontracts approved by CMS Administrator Seema Verma was routed through a larger federal contract and described to POLITICO by three individuals with firsthand knowledge of the agreements. The move by the CMS Administrator represents a break from precedent at the agency. Managed by Verma’s deputies, the deals came over the objections of some CMS staffers who raised concerns about her push to use federal funds to pay GOP consultants to amplify coverage of her own work. CMS has a capable communications shop which includes about two dozen people who handle the press.

The good news is that Congress is finally on the case now that the Democrats have the reins.

On Friday, House Energy and Commerce Chairman Frank Pallone called for an HHS inspector general probe into CMS’ use of CMS funding for communications consultants, calling it a “highly questionable use of taxpayer dollars.”

IN a statement, the New Jersey Democrat said; I intend to ask the HHS OIG to immediately begin an investigation into how these contracts were approved, whether all regulations and ethical guidelines were followed, and why taxpayers are stuck paying for these unnecessary services.”

For the record, Seema Verma is also the one who slashed the HealthCare.Gov marketing and navigator program budgets by 90% and 80% respectively over the past year and a half, allegedly in the interest of . . . “providing more efficient, targeted outreach” (via one of her press releases from last year).

Charles; I’m not sure exactly what sort of “bolstering of her public profile” these taxpayer-funded GOP image consultants are doing, but I would imagine, it is crap and similar to sending out promotional mailers like this one which showed up in my in box yesterday . . . sent from the official CMS Press Office:

Click on image to enlarge it.

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Back To School

In an earlier post, My Education In Going to College, I commented:

what was done most recently by some wonderfully-over-funded people in an effort to get their children into a Tier one school certainly did not have to happen in the manner it did. They could have just approached school authorities and with a “Thornton Mellon’s” (Back to School’s – Rodney Dangerfield) audacity, offered to pay full ride and make a sizeable donation to the school. Maybe I am wrong; but, I do not know of many schools who would turn down a half a $million donation or so and a student who is willing to pay full price at the same time. Schools are short of funding. I am pretty sure this is going on today with little being said about the donations. Perhaps, others here would disagree with me?

It appears my comment is more correct than wishful thinking as detailed in The Atlantic’s “Elite Colleges Constantly Tell Low-Income Students That They Do Not Belong.”

The Atlantic article explores Anthony Jack’s “The Privileged Poor” and gets into the detail of the prevailing wealth at top-tier schools. For instance, it is no secret, many of the students come from elite origins. For example:

“Led by the Harvard economist Raj Chetty a team of researchers found students coming from families in the top 1 percent of household incomes (those who make more than $630,000 a year) are 77 times more likely to be admitted to and attend an Ivy League school than students coming from families who make less than $30,000 a year.” I do not consider this to be a new discovery. Most people go to where they can and to what they can afford. And many end up at for-profits with a hope of achieving some type of equivalency and a chance to succeed.

“The study found that 38 elite colleges have more students who come from families in the top 1 percent than students who come from the bottom 60 percent or families making less than $65,000 a year.” Granted those 1 percenters are not the “real” rich in income as the 1 tenth of 1 percent comprising 115,000 households but, they do have enough money available to influence a school. They do count in the scheme of influencing outcomes.

14% of all the students at the elite colleges such as Stanford, Princeton, or Columbia come from the bottom half of the US income distribution. Before I go on, the author (Jack) details what he identifies as the privileged-poor and the doubly-disadvantaged. Privileged poor students come from low-income backgrounds and more than likely attended wealthy private high schools which gives them familiarity with and an acquired access to the social and cultural capital making people successful at elite universities. In other words, they know the ropes and how to get about. Doubly disadvantaged students arrive at these top institutions from neighborhood public schools many of which are overcrowded and underfunded. These students have excelled, however they are ill-equipped and lack the sociocultural tools necessary to understand the nuances of how these elite colleges operate. The doubly disadvantaged lack the social capital many students the 77-percenters and the privileged poor, the faculty, and the administrators have taken for granted. There are few mentors, councilors, or whatever you want to call them to guide them.

The advantage of the 77-percenters have is in the exposure to better schools, neighborhoods, and economics. For all intents and purposes their parents buy their way into the elite schools through private-school tuition, test prep, donations to colleges, and a myriad of other advantages which opened doors and prepared them to compete. They also rarely experience the same level of skepticism as to whether they have ‘earned’ their place as would those who enter the elite schools as a privileged poor of doubly disadvantaged.

Back to the controversy . . . rather than buy their way into the university with full price tuition and “Thorton Mellon-like” donations, these parents tried a cheaper route to getting their children admitted. Historically, the elite have used wealth to get their kids into top colleges via legal and widely recognized means—legacy, athletic admissions favoring the wealthy, and the use of test preparation to gain an advantage. Some followed the route of Thornton Mellon from “Back To School” and made or offered some nice donations meant to influence the school regardless of whether it paid for a new School of Business building or a revamped sports field.

The parents caught up in the illegal bribery opted instead for a different scheme of conspiracy and bribes. These bribes were cheaper than a building, less costly than paying for years of student preparation, going to sports games and having your child coached, and personally guiding and working with your children. Many were the vacations we took focused around soccer tournaments and many were the meetings we had with teachers and colleges.

Upfront here is the deal; a $million plus full tuition or meet me tonight at such and such place for $500,000 and full tuition. The only difference is how the bribe is made as the thumb is still on the admissions scale of yea or nay.

What is the difference? A bribe is a bribe and while one is illegal, I would say both face a test of morality.

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My Education in Going to College

As I explained in a conversation, what was done most recently by some wonderfully-over-funded people in an effort to get their children into a Tier one school certainly did not have to happen in the manner it did. They could have just approached school authorities and with a “Mellon’s” (Back to School’s – Rodney Dangerfield) audacity and offered to pay full ride and make a sizeable donation to the school. Maybe I am wrong; but, I do not know of many schools who would turn down a half a $million donation or so and a student who is willing to pay full price at the same time. Schools are short of funding. I am pretty sure this is going on today with little being said about the donations. Perhaps, others here would disagree with me?

Unfortunately, I was never so well-funded to initiate a back door funding approach such as what we are reading about today. My field of endeavor being Purchasing, Logistics, Distribution, and other similar disciplines did not command the type of salary to allow me to even hint at $hundreds of thousands or even $tens of thousands. In my field, we did not have the respect and admiration the reported actors had in their fields and accumulate such money. I was also caught in the 10 year economic cycle and one year spent time gaffing up trees and cutting them down. As Rodney would say; “Where does one go to get some respect around here?” It kept my family in one place and it paid the bills.

The Boston Globe’s Jeff Jacoby tells us what his mother said to him while a sophomore in high school; “If you want to go to college, you’d better get a scholarship.” I never had such a discussion with my parents other than my dad telling me not to do what he did. At 19 I was in the military, got out at 22, and married this pretty woman from NYC who in the beginning made more money as a Paralegal than I did with a college education. It paid the bills until such time as I caught up.

Suddenly I had responsibility for more than just myself. So I picked out a small Lasallian Catholic college, used my VA bennies and the state grant to pay for it, and finished up in three years. Never thought of Northwestern or University of Chicago as neither were in the cards and my parents would not have understood it much less pay for either. As a good Baptist I chose a Jesuit University over a Vincentian University for my Masters. Going to school at night then seemed to drag on forever. It was years later when I found out the high school and colleges I attended were pretty good schools. Each year, I donate a few hundred and get invited to various functions which I do not attend. I do not know anyone at these schools other than the Deans.

As advice to my own children, I suggested they go to where the money was. If they offered you grants and scholarships, they wanted you. If all they could conjure up was a subsidized Stafford loan at $3,000/year for a $30,000/year education, they were telling you something. Thank the school for their time and move on to the next one. In the end, it worked and we were also able to finagle a few more $thousand yearly at some pretty good small colleges for each. They do well for themselves and have paid their school loans.

As I sit here in my Levi jeans and ratty-looking Jesuit University sweat shirt writing this, I find myself agreeing with Jacoby and confirming what I already know; “No one needs to attend an elite university to get a decent education or to make a success of their lives, just as no one needs to wear a Dolce and Gabbana sweater to keep warm or drive a Ferrari Enzo to get from here to there.

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PFAS Contamination, the New Flint at Military Bases and Again in Michigan

In parts of Livingston and Oakland counties, the people have been warned not to eat the fish from the Huron River and Kent, Strawberry, Zukey, Gallagher, Loon, Whitewood, Base Line and Portage lakes as well as Hubbell Pond due to the fish being contaminated with PFAS and similar chemicals coming from industries. In 2016, Michigan started to tell people about the impact of PFAS and how dangerous the PFAS and PFOAs are.

PFAS/PFOA are part of a class of man-made chemicals used in many industrial and consumer products to make the products resist heat, stains, water, and grease. Product Examples include: Teflon® cookware, waterproofing fabric and coating on fast food wrappers.

Former Army reservist Spc. Mark Favors, his relatives, and family have lived around Fort Carson and Peterson Air Force Base for years drinking and bathing-in base and off-base water for years. The level of PFAS and PFOA on base around Peterson Air Force Base has been established at 79 to 88,400 parts per trillion on-base wells and 79 to 7,910 parts per trillion in public and private drinking wells off base.

It was not until the EPA published its 70 parts per trillion guidelines did the DOD claim it began to understand how harmful exposure could be and voluntarily took action. Spc. Mark Favors does not buy the excuse. The issue has been explored in-depth by the Colorado Springs Gazette, which produced a timeline dating back to the first concerns about the foam used to fight fires in 1962. Fort Carson stopped using the firefighting foam in 1991 stating, “Firefighting operations that use AFFF must be replaced with nonhazardous substitutes.”

In Michigan, it will take a Flint-sized emergency before it begins to take aggressive action with businesses dumping contaminated water in company drainage pipes going to water reclamation plants. Then too, Livingston County is the richest in income in the state and is also 96% white, an advantage the county has over the City of Flint.

Fifty year old Mark Favors can count at least 16 relatives from around the area who have been diagnosed with cancer; 10 have died. Six of those relatives have died since 2012, including his father at age 69 and two cousins, ages 38 and 54.

“In my family alone, we have had five kidney cancer deaths,” Favors said. “And those people only lived in the contaminated area.”

Many of Favors’ relatives lived near Peterson Air Force Base, where scores of both on-base and off-base water sources have tested significantly above the Environmental Protection Agency’s recommended exposure of 70 parts per trillion of perfluorooctane sulfonate (PFAS) or perfluorooctanoic acid (PFOA). The compounds were part of the military’s firefighting foam until just last year. The same compounds in the foam have been linked to cancers and also developmental delays for fetuses and infants.

In a recent March 6, 2019 House subcommittee hearing, Mark Favors was among those in attendance as the subcommittee was questioning the actions of the Environmental Protection Agency and Department of Defense representatives over the decades long use of PFAS, the failure to regulate it’s usage, provide adequate protection from its usage, and monitor the safe disposal to prevent contamination of ground water and the environment. Knowing its dangers, a reasonable person would have found an alternative to its usage as demonstrated by Fort Carson in 1991. Obvious, some elements of the military were not of that mind.

With a large degree of politeness, House Oversight and Reform subcommittee on the environment chairman Rep. Harley Rouda, D-CA commented:

“To put it charitably, it is unclear why DoD feels justified in passing the buck to the EPA, particularly in light of the evidence suggesting DoD’s awareness of the toxicity of the chemicals since the early 1980s.”

If stationed at a military bases (and who has not been for some period of time?), this is a big issue as many of us were using the water supplied to us at places such as Camp Lejeune where we were drinking and showering in water contaminated with chemicals such as benzene. For those who were at Camp Lejeune for at least 30 days, there is now a list of disorders which the VHA will accept as being attributed to exposure to base water. Some of us have disorders on that list and some of us do not. There are many other military sites where former military and civilian personnel have complained of disorders and illness which they believe is attributed to the bases they were stationed during their enlistment or working as civilians.

In Michigan, there is a site where you can get an idea of how bad the issue is in and around your community. All known PFAS sites in Michigan and check your own area (at the bottom you scroll to find your county and township/community).

Many knowledgeable sources believe the 70 parts per trillion is still too high.

by run75441 (Bill H)

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Brooklyn Heights, NY

Click on the picture to get a great, detailed view of these magnificent and architecturally significant structures. Claude Scales’s Photo of the day: there is a lot of Brooklyn Heights literary history in this photo.

The poet W.H. Auden lived in the top floor apartment of the brownstone row house at One Montague Terrace, nearest the corner of Montague Street and Montague Terrace, in the winter of 1940-41 when he wrote his “New Year Letter.” If you go to the right two doors, to 5 Montague Terrace, you find the house where Thomas Wolfe (not to be confused with the recently deceased Tom Wolfe) worked on his novel “Of Time and the River.” On the left of the photo, the building with the cylindrical tower and turreted top is where the playwright Arthur Miller and his first wife, Mary Slattery, lived during the early years of their marriage, and where he began work on his first Broadway play, “The Man Who Had All the Luck”. — in New York, New York.

Love the buildings and maybe because I worked on a few similar to them using rope or cable suspended scaffolds and ladders in downtown or near downtown Chicago. Harvard attorney Claude Scales is the photo-artist-author of this snapshot and commentary stolen from Facebook. I know him from when I would comment at Slate Magazine (along with JackD) when it was a cool place to be. Editor Moira Redmond (not to be confused with the English actress) described the Best of The Fray site, “the place I would tell the other editors to go to if you wanted to find out what Americans were actually thinking.”

Hope you enjoy . . .

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Light Sentence

“Legal observers were surprised by the relatively light, 47-month sentence received Thursday by President Trump’s former campaign chairman Paul Manafort, who was convicted in August on charges of tax and bank fraud.

The 69-year-old, who appeared in the court in Virginia in a wheelchair and pleaded for compassion, could have been sentenced to up to 24 years in federal prison.

With time served, Thursday’s sentence means Manafort could spend a little more than three years behind bars for this case.

NBC News and MSNBC legal analyst Glenn Kirschner: ‘As a former prosecutor, I’m embarrassed. As an American, I’m upset … I am just as disappointed with Judge Ellis. It’s an outrage and it’s disrespectful of the American people.'”

I have been in level 4, 2, and 1 prisons. I used to chase prisoners a long time ago. None of these prisons are a walk in the park. The prison up in Pugsley, Michigan was a level 1 and one of the most dangerous ones in the state as they transferred a bunch of long timers there who did not give a . . . . . you know what I mean. For this peace of garbage ‘Manafort’ it has to be a huge let down having to associate with the lesser human beings who will be making fun of him. Lets see what the next sentencing brings. If they run it consecutively and it goes over 10 years, he will go to a Level 4.

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Pentagon to Tap Leftover Military Pay Funding

“The Pentagon is planning to tap $1 billion in leftover funds from military pay and pension accounts to help President Donald Trump pay for his long-sought border wall, a top Senate Democrat said Thursday.

Sen. Dick Durbin, D-IL ‘It’s coming out of military pay and pensions. $1 billion. That’s the plan.

The funds are available because Army recruitment is down and a voluntary early military retirement program is being underutilized.’

The development comes as Pentagon officials are seeking to minimize the amount of wall money that would come from military construction projects that are so cherished by lawmakers.

‘Imagine the Democrats making that proposal — that for whatever our project is, we’re going to cut military pay and pensions.'”

Gee, did anyone ever think of tossing this into the VHA funding since the VA now has to pay for the Choice program which Trump said he will not fund.

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The Lost People . . .

Over heard in the Comments Section:

EMichael: “I do love the term ‘Goober Safari’”.

“I am as tired as anyone else is at the seemingly endless Goober safaris into those benighted precincts of Americans who helped hand us El Caudillo del Mar-a-Lago as our president*. I am even more tired of being told that the prescription for getting rid of this guy is to romance the daylights out of the unreconstructed ignorami who voted for him in the first place.

So imagine my complete lack of surprise when The New York Times sent yet another expedition out into the hinter-boondocks to see what the plaid-cap and camo set is thinking these days.

‘But, listening to strategists and voters in a critical state for Democrats, the midterms feel like a long time ago. Instead, there are widespread worries that the momentum in Pennsylvania, and in other key Rust Belt states, could screech to a halt if the issues in the 2020 presidential primaries and the party’s eventual nominee stray too far left for the region’s many centrist voters. “The more we have presidential candidates or newly elected congresspeople talking about the Green New Deal, talking about ‘Medicare for all,’ talking about socialism, the more that plays into the Trump campaign’s hands,” said Ed Rendell, a former Pennsylvania governor and national Democratic chairman.’

Jesus H. Christ in a wax museum, have we not heard enough from Ed Fcking Rendell? No presidential candidate—except Donald Trump—is “talking about socialism.” The Green New Deal and Medicare For All are new policy proposals growing from policy positions and philosophies held by Democrats for at least 40 years.

Both are “a Yuengling order for a Pennsylvanian right now,” said Ryan Costello, a former Republican congressman from suburban Philadelphia. That is, someone as familiar as the beer brewed in Pottsville. Mr. Costello said that by nominating a progressive in 2020 — he named Mr. Sanders and Elizabeth Warren — the general election would become a referendum on far-left policies rather than the president.

“The whiplash on the left right now, it’s almost like they didn’t learn the lesson of why they were successful in 2018,” Mr. Costello said.

One of the reasons “they” were successful, of course, was that people like Costello ran like rabbits away from their congressional seats because they saw what was coming at them. So, sure, let’s make certain that Democrats listen to the likes of him. And, of course, there is that stubborn Economic Anxiety in some of these areas that just won’t go away.

We had eight years of nothing,” said Diane Pappert, 75, a retired school guard, referring to President Barack Obama, “and this guy’s trying to clean up everybody’s mess.” Her daughter Angie Hughes, 55, a nurse, had cast the first vote of her life for Mr. Trump. She said she would never vote for a Democrat because she believed that the party favored generous welfare benefits. “When you see people who have three, four, five children to different fathers, they have no plans of ever going to work,” she said.

and then there is . . .

Lou Iezzi, 68, who still works at an auto garage he opened at 19, had voted Democratic for decades before casting a ballot for Mr. Trump. He liked the way he sounded as if he were on the next barstool, and Mr. Iezzi chuckled approvingly recalling Mr. Trump’s dismissive remarks about the newscaster Megyn Kelly in 2015 that were widely interpreted as referring to menstruation. Mr. Iezzi could vote for a Democrat in 2020 if the nominee “sounds like he’s talking honestly,” he said. His choice of the male pronoun was deliberate: “I just can’t see a woman running this country.”

Whadda guy! Buy him a Yuengling. But, for the love of god, don’t tailor a single policy position toward gaining his support. He’s hopelessly lost.”

These People Are Lost. Democrats Shouldn’t Bother Chasing Them., Charles P. Pierce, Esquire Magazine

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