Relevant and even prescient commentary on news, politics and the economy.

Medicaid Expansion 2018

Four states had the Medicaid Expansion on the ballot this last election and another is still fumbling around with expanding it..

The Good

Idaho: Idahoans approved Idaho Proposition 2, an initiative requiring the state to submit an amendment to the Centers for Medicare and Medicaid Services (CMS) in order to implement the Medicaid expansion no later than 90 days after the approval of the act. The Idaho Department of Health and Welfare is required and authorized to take all actions necessary to implement the provisions of this section as soon as practicable and outgoing Governor Butch Otter endorsed the ballot initiative less than a week before the election and Republican Governor-elect Brad Little has said he will implement the initiative.

Nebraska: Nebraskans voted in favor of Initiative 427 requiring the state to submit an amendment/documents seeking waiver approval from CMS on or before April 1, 2019 to expand Medicaid. As directed by the initiative, the state Department of Human Services to “take all actions necessary to maximize federal financial participation in funding medical assistance pursuant to this section”. Although newly reelected Governor Pete Ricketts has been a vocal opponent of expansion, he has stated he would let the voters decide if it made it onto the ballot.

Utah: Voters approved Utah Proposition 3 calling for the state to expand Medicaid coverage beginning April 1, 2019. The initiative also prohibits future changes to Medicaid and CHIP that would reduce coverage, benefits, and payment rates below policies in place on January 1, 2017. The proposition calls for a 0.15% increase to 4.85% from 4.7% the state sales tax (except for groceries) to finance the expansion or Medicaid and CHIP more broadly.

The Bad

Montana: Montanans voted down Montana I-185 after spending on campaigns for and against the initiative made it the most expensive ballot measure race in Montana history. The measure proposed raising taxes on all tobacco products and e-cigarettes and vaping products to dedicate a percentage of increased tax revenues for Montana’s current Medicaid program and veteran’s services; smoking prevention and cessation programs; and long-term care services for seniors and people with disabilities. The initiative also would have eliminated the sunset date for the Medicaid expansion of June 30, 2019. Republican controlled Montana State Legislature could still take action to continue the expansion program beyond June 2019. Tobacco companies had spent more than $17 million on advertising and other efforts to oppose the ballot measure, most of which came from cigarette maker Altria (Philip Morris).

The Ugly

Maine: Maine. Medicaid expansion was adopted in Maine through a ballot initiative in November 2017. Governor Paul LePage resisted the implementation of it and then complied with it after the Maine SC ordered him to submit an expansion state plan amendment (SPA) to CMS. He did submit the plan along with a asking CMS to reject the SPA. The newly elected Democratic governor, Janet Mills, has supported Medicaid expansion and is likely to move quickly to implement. Democrats also control the Maine legislature.

The ACA has shown up more in this last election even though it is pretty much a done deal and near impossible to repeal. Still Republicans repeat the same old “lies” even though they have been shot down repeatedly. One often repeated lie is the Democrats and the ACA stole $800 billion from Medicare to fund it. This lie was used by Mike Bishop in Michigan and our President also. Quite the opposite occurred with the Medicare TF being extended for a few more years and excess payments to Advantage plans reduced to match what Medicare pays out.

More to be read here: What Does the Outcome of the Midterm Elections Mean for Medicaid Expansion?

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Michigan Medicaid Waiver

The State of Michigan Legislature is applying for an ACA Waiver as I pointed out in my post Why States Should Not Be Allowed to Alter the ACA with Waviers

This is a relief valve for “counties” with high unemployment. In effect if Michigan counties have a high unemployment rate (8.5% or above), the unemployed workers in that county can have Medicaid until such time as the Unemployment Rate drops to 5%. Then the workers are expected to seek employment to be eligible for Medicaid. Ok, that should cover Detroit, Flint, Saginaw, Muskegon, etc. high unemployment rate. which exceeds 8.5%. Or does it qualify them?

The issue with SEC 107B is the word “Counties.” By using solely the word counties, SEC 107B does not make an exception for townships, villages, or cities. For example, Wayne County has an unemployment rate of 5.5% and not 8.5% or greater. As a result, Detroit which does have an unemployment rate greater than 8.5% and sits in Wayne County does not qualify for a Medicaid exemption because it is not a county. Neither would the other Michigan cities in other counties with low unemployment rates qualify. Set this aside for a moment.

The waiver strips predominantly Black populated Michigan cities of Medicaid if the county in which the city resides has an unemployment rate lower than 8.5% even though the city has an unemployment rate higher than 8.5%. Additionally and besides a work requirement of 29 hours per week, the bill will end Medicaid and expanded eligibility for residents after they’ve been on Medicaid for 48 months for those earning between 100% and 133% FPL and eliminate the option to extend coverage by completing healthy behaviors.

To force the issue with lame duck governor Rick Snyder, the Senate on Thursday (May 7th) approved a $56.6 billion budget which includes a suspension of the salaries of Health and Human Services Director Nick Lyon and other top officials in the department if Governor Snyder does not request and secure a federal waiver to implement the Republican legislation passed Medicaid work requirement, and other proposed parts of the legislation. The CMS has already blocked a lifetime limitation on healthcare in Kentucky’s waiver request. When the legislature includes a particular mandate on a budgetary piece of legislation, it can not be overturned by a vote. Both the House and the Senate are controlled by Repubs.

It is unlikely the CMS will approve Michigan’s waiver as they have already blocked Kansas and I believe Kentucky.

Sponsor of the Legislation Sentaor Shirkey:

“This is personal for me, because I laid a lot of political capital on the line to try to get this done,” (Shirkey coaxed fellow Republicans to support the Medicaid expansion in 2013 but is now leading the reform effort).

I still believe it was the right thing to do, but I’m not going to go back on the promises that were made to get those votes.”

Republican Michigan State Senators Shirkey and Joseph Hune have lifetime healthcare benefits which they passed for themselves in 2012.

run75441 @ Angry Bear Blog

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More On the Real Reason Healthcare Insurance Companies Are Now Encouraging Obamacare Enrollment

In light of some of the comments to my post yesterday arguing that that the real reason that healthcare insurance companies are now madly encouraging Obamacare enrollment is fear of a pro-public-option or pro-single-payer political juggernaut, I want to make clear that by single-payer I do not mean Medicare-for-all.   Single-payer would be, in essence, “the public option” extended to everyone rather than limited to the 5% of Americans who have private healthcare insurance through the non-group (i.e., non-employer-provided) market.  It is not tax-funded identical-for-all healthcare insurance, which is what Medicare is.  I do think that eventually this country will have Medicare-for-all-type healthcare insurance, but not in the near term.  If single-payer works well, then of course that would be the longterm solution, with no need for Medicare-for-all.

I also want to make a point about federalism as it relates to the ACA insurance-market exchanges and, especially, to Medicaid and, for that matter, to any other federal social-safety-network program.  I said in my post yesterday what I think is obvious: that federalism has been a disaster for Obamacare.  But I want to point out that the only reason that Medicaid works under current pre-Obamacare Medicaid is that that program came into being and was effectuated before the hard-right turn of the Republican Party.  Ditto for food stamps.  The really weird, but successful, argument by rightwing governors and state attorneys general to the Supreme Court in the ACA litigation on the Medicaid-expansion provision in the ACA is that, well, y’know, now that traditional Medicaid has been a part of each state’s law for decades, and is popular, it would be politically impossible for state legislators to end that program–the result under the ACA as the statute was written, if a state refused to agree to the ACA Medicaid expansion.  This, they argued–successfully!–meant that the ACA was effectively coercive of state  legislators and therefore infringed upon state sovereignty.  On that “ground,” the Supreme Court struck down that part of the Medicaid portion of the ACA.

That’s also known as the  conservatives-having-their-cake-and-eating-it-to theory of constitutional law.  The argument was so deeply hubristic that its actual success is stunning and outrageous.  But I have no idea why anyone would think that federalism must be a part of a national healthcare insurance law. It does not.

As for whether or not the public will catch on that the main problems with the Obamacare-exchanges-and-private-policies part of the Act is a failure of the healthcare insurance market and of the healthcare market itself–a question that several commenters raised–well, that was what my post was about.  Yes, the public will catch on, once the Dems have a smart, committed, knowledgeable and articulate spokesperson with a high enough national profile to educate them about it.  I expect that that will happen fairly soon.

Finally, although this should be the subject of a separate post, a hallmark of the current Supreme Court is how many really weird, outlandish rightwing arguments the current conservative-legal-movement five-member majority have made the law of the 50-state-soverign-lands.  As I said in an ignored post here last weekend, the Court’s neo-federalism-on-steroids jurisprudence has quietly but profoundly and thoroughly upended federal-in-relation-to-state constitutional law as it had existed since the post-Civil War era. This is a deeply dangerous juggernaut.

I wish more readers would read that post.  It does deal with really important stuff. Honestly.

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In the Short Run, We Are All Dead. At Least According to That New Oregon Medicaid Study.

Well, we AB types–readers and writers, alike–are familiar with John Maynard Keynes’s famous line that “In the long run, we are all dead.”  By which he either meant that economists, if they are to be useful, must try to predict and recommend short-term government policies that avoid or help end current, severe economic downturns, rather than just predicting long-term economic results, or instead he meant that since he was gay and had no children, he didn’t care about the long-term economy and wanted economic policy to concern itself only with the here-and-now and never with the long run.

It’s a fielder’s choice, if you ask me.  Which is why you shouldn’t ask me.  And you shouldn’t ask Niall Ferguson either.

Conveniently, in the very same week in which high-profile economists are debating what Keynes meant, we learned that a study of the effects of access to healthcare insurance (in that case, through Medicaid) shows that access to healthcare does not reduce cholesterol levels, blood pressure, or blood-sugar levels, over a two-year period among people who have elevated levels of one of another of these ailments and who were not previously receiving medical treatment for them because they had no insurance. At least it did not in Oregon, where the study took place, for the sampling involved.

The study is being widely interpreted as showing that healthcare insurance does not improve actual health, and has lead some people to suggest that this means that we should not have healthcare insurance at all, whether publicly or privately financed.

But that’s ridiculous. Or at least it’s insufficient as a response.  What the study obviously shows is not simply that we shouldn’t have healthcare insurance but that we shouldn’t have healthcare. We should not have medical care.  At all.  No doctors, no hospitals, no prescription drugs, no medical devices.  None of it.  We’re spending huge amounts of money on healthcare, and now we know that it doesn’t improve health!

In the long run, we are all dead.  And if you have no access to healthcare and have, say, a heart attack, a stroke, cancer, a diabetic coma, or a serious physical injury, you may well die without medical attention even if you would have lived if you’d had medical attention. In the long run, we are all dead, and in the short run those who have a life-threatening illness or injury and no access to medical care may be too, even if access to medical treatment might have lengthened that run quite a bit.*

So we need to end the medical-industrial complex, because, after all, how much difference is there, really, between the long run and the short run?  Lipitor, insulin, and blood pressure medications are okay, I guess, if you have nothing better to spend your money on.

But even if you don’t, why throw your money away on stuff like that, when those things don’t even improve your health?  And, as for the government and Medicaid, and Obamacare, and Medicare, and all that: Well, what’s that line about, families are tightening their belts, so the government should, too?

At least now we’ve finally found the way to stop healthcare inflation.  End healthcare itself.

*Paragraph rephrased and clarified after initial posting, to avoid possible misinterpretation.

___

UPDATE:  This post, though obviously satire targeted at the rightwing’s conclusions about the study, also is intended to raise what seems to me a critical medical question that, to my knowledge, no one else has asked: Does the study indicate that the treatments for high cholesterol, high blood pressure, and early-stage diabetes are ineffectual?

It may be that the diet recommendations given to these new Medicaid patients–less salt, low sugar, lower-cholesterol diets, respectively–weren’t adhered to by most of the patients.  Or it might mean that, once diagnosed with one or another of these illnesses, those in the study who did not get Medicaid nonetheless changed their diet somewhat in light of the diagnosis.  Or it might mean that the medications that were prescribed for the Medicaid recipients who did obtain medical treatment are less effective than thought–which strikes me as something that should have been the headline takeaway, but obviously was not.

If there’s some other possible meaning to the study’s results, what is it?  Seriously.  If these treatments are medically ineffective, isn’t that something that the public should be told?  And if the treatments are effective in the general population, then why would these very same treatments–specifically, the medications–not work with the Medicaid recipients in the study? And, why aren’t these the questions that the pundits are asking?

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Medicaid Austin Frakt, Aaron Carroll and Kevin Drum are Good for the USA

by Robert Waldmann

An important study of the effect of Medicaid on health was published in the New England Journal of Medicine.  The study was based on a genuine experiment where some people were given Medicaid and other people weren’t based on a lottery.  Unfortunately, the results were communicated with a NEJM  press release and not just the published article.  The results as received by the press is that Medicaid did not cause significant effect on recipients’ health (except for significantly lower depression) which was interpreted as the study providing evidence that Medicaid does not improve health.

This means that somehow someone rejected the alternative.

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Rep Marsha Blackburn’s snow job. Explains how Social Security money flows

I was watching C span Washington Journal this morning.  Rep Marsha Blackburn was the guest.  I got to listen to her explanation of how the Social Security funds flow and just had to post the clip.   Copied from the transcript of the clip:

THEIRS MONEY THAT GOES TO MEDICARE AND SOCIAL SECURITY AND I THINK IT IS JUST IS SO INAPPROPRIATE THAT THE FEDERAL GOVERNMENT DOES NOT USE THAT AS A TRUST FUND BUT THEY MOVE IMMEDIATELY TO THE GENERAL FUND AND STACK UP IOU’S THAT ARE SITTING IN A CABINET IN WEST VIRGINIA.

What she says should not be allowed to stand and if C-span were half of what it used to be, she would not have had the following go uncorrected.  Thus I leave it to the Angry Bears to correct her here and thus document her ignorance of the subject. 

I have not watched this lady before.  I could not help but think she is just a more polished version of Sarah Palin. She is totally capable of pulling off what we used to call a “snow job” when writing their essay.

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The "Fiscal Cliff" and the Coming Retirement Crisis of the Middle Class

On January 1, Congress approved a tax and spending bill to avert the so-called “fiscal cliff” combination of tax hikes and spending cuts that would have created deflationary pressure on the United States (though Yglesias questioned the conventional wisdom of whether it would necessarily cause a recession). Let’s take a look at the deal in some detail, then proceed to the gruesome details of what will happen around the Ides of March.

From Think Progress, here are some of the more critical parts of the deal.

1) The Bush tax cuts expire on only about 0.7% of households, those earning more than $400,000 per year as an individual or $450,000 for a couple. This brings in $600 billion over 10 years. Since rich people don’t spend as much of their income as the poor and middle class do, this is less deflationary than a tax increase on the middle class, as I discussed in November.

2) With the expiration of the temporary 2% payroll tax cut, 77% of households will see their taxes go up. Indeed, every single income group will, on average, see their taxes increase, as shown below (via Matt Yglesias):

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Since this hits the middle class more directly, the deflationary consequences are larger than they would be for an increase in taxes on the rich. On the other hand, this strengthens the long-run funding of Social Security, an issue I will return to shortly.

3) Unemployment insurance is extended for two million workers. This will get spent and have a definitive stimulative effect on the economy.

However, the second shoe of the fiscal cliff, the automatic cutbacks known as the “sequester” was simply postponed for two months, which is the same time that the Treasury Department will run out of creative ways to keep the country from exceeding the debt ceiling, which it hit on December 31.

Combining these two negotiations, the debt ceiling and the sequester, will be an extremely high-stakes battle where the middle class has a lot to lose. The big problem here is that some Tea Party Republicans really do want to use the debt ceiling to take the economy hostage and force cutbacks in Social Security, Medicare, and Medicaid. Despite the fact that Republicans lost the Presidency as well as both Senate and House seats (with a majority of the votes cast for the House going to Democrats), they see their gerrymandered House majority as giving them license to wreak havoc.

The consensus among most commentators (Krugman, Klein, and Yglesias, for example) is that the fiscal cliff deal will work out okay as long as the President does not cave in to the Republicans’ threats over the debt ceiling.  I agree as far as that goes. But, as Yglesias points out, there is nothing great about what Klein says is the most likely scenario, where the President gets $1 trillion in new tax revenue for $1 trillion in cuts over 10 years. That is still $2 trillion in austerity measures at a time when unemployment is barely below 8%!

The looming problem rarely mentioned, even in the context of the Republican campaign against Social Security, is that my children’s generation (Generation X, if you will) faces a retirement crisis that many of my generation will avoid, based on the end of pension plans. According to one Social Security Administration report, the percentage of private-sector workers with a traditional defined-benefit pension plan fell from 38% in 1980 to 20% in 2008. Over the same period, private-sector workers who only received defined contribution plans rose from 8% to 31%. Note that this means that 49% of private-sector workers are not covered by any pension plan at all. Moreover, while governments have more commonly provided defined-benefit plans than private employers have, they are under attack in many states.

Let’s do the math. With 49% of private workers having no pension, and another 31% having an on-average less generous defined contribution pension, how will seniors support themselves if Social Security is cut? Hint: It won’t be pretty.

Get ready for a bumpy March.

Cross-posted from Middle Class Political Economist.

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Let’s try to stick to the real world when we talk about Medicaid,

The Incidental Economist addresses election snippets that keep on going, just like in the movies.  Read the whole thing:

Let’s try to stick to the real world when we talk about Medicaid, by Aaron Carroll:

(Note: Paul Krugman cites here. Tyler Cowen responds here. I respond to Cowen’s response here.)

Tyler Cowen had a piece in the NYT this weekend on Medicaid. He doesn’t seem too thrilled with its use in the ACA’s coverage expansion.

… I have to admit that his article set me off a bit. It could be that he didn’t have space in the NYT for more nuance. Perhaps he’ll provide it on his blog. In particular, I’d love him to address some of the points below…

I get a bit annoyed by blanket claims that doctors won’t accept Medicaid….
I get a bit annoyed when people just claim government programs are “unpopular”…
I get a bit annoyed at the blanket acceptance of the awesomeness of the free market in health care, when there is no phenomenal evidence of its success…

Look, I get that people may not like the political implications of those systems. They may not like the governments that produce them. They may not like the lack of choice  inherent in such systems. They may not like the potential  limitations within them for making money, and therefore for innovation. But we need to stop making stuff up about them.

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Health Care Thoughts: Another Major Event

by Tom aka Rusty Rustbelt

Health Care Thoughts: Another Major Event

On the 23rd the Obama administration will publish the administrative regulations for Medicaid expansion.

http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/REG-03-16-12.pdf

As reported by Modern Healthcare, eligibility will be simplified to an income test as a percentage of the federal poverty level. This may expand Medicaid by as many as 17 million recipients by 2016. There are a number of administrative issues addressed, many focused on simplifying and streamlining processing.

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Town Hall Meetings on the Ryan Budget Raise Concerns

Various congressional representatives held town hall meetings recently, and the news channels and print media were abuzz with the lively give-and-take, including shouting matches. See, e.g., House G.O.P. Members Face Voter Anger Over Budget, New York Times, Apr. 26, 2011; Republicans facing tough questions over Medicare overhaul in Budget Plan, Washington Post, Apr. 22, 2011.

The issue–the House’s adoption of the Ryan budget proposal and its clear agenda of overturning New Deal safety nets embodied in the current understanding of Medicaid, Social Security and Medicare.

Those at or near retirement are worried that the Ryan proposal will hurt everybody. The Ryan proposal comes with frequent disclaimers about protecting the already older population and needing to act now to protect our grandchildren, a clear effort to massage the message to appeal to current grandparents. See, e.g., House G.O.P. Members Face Voter Anger Over Budget, New York Times, Apr. 26, 2011 (noting Webster’s statement that “not one senior citizen is harmed by this budget” while implying that it is necessary to prevent grandchildren from “looking at a bankrupt country”); Congressional Republicans go home to mixed reveiws, CBS.com, Apr. 26, 2011 (noting North Carolina GOP Rep. Renee Ellmers’claim that “If you’re 55 and older, your Medicare and Social Security will not change”).

But the Ryan proposal clearly envisions mechanisms that would likely lead to decimation of these programs–either through turning them into limited vouchers (Medicare proposal); turning the funds over to the states to use as they see fit (Medicaid proposal) or limiting benefits (Social Security proposal) in ways that will –probably sooner rather than later– hurt everybody.

  • These proposals take place in a context of expansive, concerted attacks on these “entitlement” programs, often failing to acknowledge the historic support for these programs or their foundation in the recognition that federal support is required to protect against the abject poverty and humiliating degradation that accompanied the Great Depression;
  • Benefits for elderly and sick Americans are cut to provide savings to offset some of the loss of revenues from tax cuts for Big Business and the wealthy, both of whom already pay relatively low taxes, in what hardly seems a bargain to the working poor, the elderly or in fact the overwhelming majority of Americans who are not in the top 15% income or wealth distribution. (This in spite of Ryan’s claim that there is no huge tax cut for big corporations and the wealthy–he asserts that the proposed 25% rate is “in exchange for losing their tax shelters”. See, e.g., CBS.com Evening News coverage of Paul Ryan holding Wis. town meetings, at http://www.cbsnews.com/video/watch/?id=7363939n&tag=related;photovideo )
  • In spite of the high cost for the vulnerable poor and elderly of these budget proposals, they don’t appear likely to achieve their proffered rationale of reducing debt and deficits–in fact, the CBO has said that the Ryan budget proposal will result in higher deficits and bigger debt burdens over the next decade.
  • It appears shortsighted to wring one’s hands about a “bankrupt country” while considering only one potential solution, especially when that solution is highly detrimental to the most vulnerable populations, and without considering the full facts regarding the amount of debt, the ability of the U.S. to weaken the dollar further to aid unemployment and debt payment, the ability of the U.S. to raise taxes judiciously rather then merely cutting spending, or the ability of the U.S. to let the tax law play out as it is currently slated to do (with the Bush tax cuts that were extended 2 more years over their originally intended short life due to sunset in 2012). As Jim Johnson, a former Ryan supporter who has “grown increasingly disgusted” with Ryan noted, “[Ryan] says Medicare is unsustainable. I’m thinking, ‘Yeah, it’s because medical costs are out of control.’ …Why isn’t he attacking it at that level?” Congressional Republicans go home to mixed reviews, CBS News.com
  • Any voucher system for health care will inevitably fail to cover increasing health care costs, resulting in rationing even the most basic health care by socio-economic class–the very problem that Medicare, Medicaid, and the limited health care reforms undertaken by the last Congress were intended to address. The Center for Budget and Policy Priorities concluded that out-of-pocket medical costs would skyrocket for low-income seniors; the Washington Post’s Fact Checker Glenn Kessler (in GOP Lawmakers tout Medicare reform by stretching a comparison to the health benefits they receive, Apr. 29, 2011) notes that the CBO analysis concluded that the Ryan Medicare system would pay only 32% of health care costs by 2030, compared to 70-75% if traditional Medicare remained in place.
  • Addressing the problems in the U.S. health care system solely by market means that put the onus on health care recipients to seek cost-savings has failed miserably over the last forty years and cannot help but fail more spectacularly when the Medicaid backup is weakened and the nature of health care needs is such that one of the best antidotes to market problems (the only one permitted in radical market thinking that objects to regulatory safeguards)–informed consumers who can review options and select among competing providers–is simply not applicable. Car accident victims don’t shop for surgeons; cancer victims don’t know enough to select based on price; etc.
  • The Ryan proposal appears one-sided in its decision to cut spending on potentially vulnerable populations rather than to address the means through which health care is provided or to consider ways to control profit-taking in the health care system. The market ideology of the proposers leaves many options that might work better off the table (single payer; tax on excessive compensation; revamping the non-profit hospital system; attaching strings to the R&D and other tax expenditures in the tax code; using the clout of a national system to negotiate better doctor and drug pricing for Medicare and Medicaid, etc.);
  • Many of those states that would acquire more control over the use of Medicaid funds are controlled now, as is the House, by people who have announced their intent to cut taxes on the wealthy and business while cutting or taxing pensions and health benefits for public employees and cutting funds available for Medicaid and other poverty-directed programs; it is not a difficult leap to see the interrelationship of these trends;
  • Plans to cut benefits for those who may enjoy them in the future pave the way in at least two ways for decisions shortly thereafter to cut benefits for those who currently enjoy them: first, by creating lowered expectations; second, by creating an unfair disparity that supports an “us against them” attitude between the current elderly and those who will get lesser benefits in the future. (Note that this resembles the way the right has encouraged an “us against them” attitude of private workers, who have been deprived of union benefits through the harsh anti-union tactics used by Big Business, against public employees, who have generally benefited in the past from more reasonable attitudes towards unions fostered in legislative bodies that have, in the past, understood the nature of the bargain that public employees make (which might be summarized as ‘work hard, get paid less than you could in the private sector, and accept later benefits in pensions and health care for lesser salary/percs now).

Is is surprising that left-leaning activist groups like Move-On point to the Ryan budget proposal as a “naked, unapologetic attack on working Americans for the sake of Big Insurance and the riches of the rich” (quote from Move-On email on this matter)?

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