Conservatives vs Pre-Existing Conditions

 

The CBO score for the House Republican health bill came out last week and the news is “unexpectedly” bad: 14 million more people uninsured next year and 26 million by 2026.  These numbers are crap of course.  Not just because the CBO is notoriously wrong (remember their rosy predictions about Obamacare?) but because their comparisons are not based on reality.  As the Legal Insurrection site notes, the CBO used a March 2016 baseline that they had previously acknowledged was wildly inaccurate. With health plans dropping like flies from Obamacare exchanges all over the country, if you do nothing, you’re likely to get a similar result of increase in uninsured by 2026.

But the purpose of the CBO report wasn’t to provide a statistical analysis of the possible effects of a healthcare replacement plan, it was to provide talking points to the Democrats, and on that basis, mission accomplished.  And that’s why Mitch McConnell is trying to stall bringing up the healthcare bill in the Senate for as long as possible.  It’s a policy, political, and PR nightmare.

But the real nightmare in the health care debate boils down to the one issue that actually frightens people, stirs them to show up to town halls, and dominates the cable news coverage of health care policy is pre-existing conditions.  How to handle pre-existing conditions occupied the majority of debate on the House plan, and ultimately failed to satisfy.  The AHCA has planned to handle pre-existing conditions through high risk pools.  The way they are supposed to work is that people with pre-existing conditions would sign up for their health plans like normal, but money set aside in high risk pools in each state would go to subsidize the insurance companies directly for each customer with pre-existing conditions.  This was based on a highly successful program in Maine. The problem with rolling that out nationwide is that we have no good way to estimate either the costs per person or the number of people involved.

Our guide to how little we know about the pre-existing population lies in an Obamacare program called the Pre-Existing Condition Insurance Plan (called either PPACA or PCIP). PCIP was set up to provide health insurance as a bridge until the requirement for individual health plans to accept everyone, regardless of pre-existing conditions, kicked in. The assumptions were wrong both in number of enrollees and how much they would cost.  The original cost estimate per enrollee was $13,026.00 and in only 11 months was upgraded to $ 28,994.00 per enrollee. And how many people are affected by pre-existing conditions?  Up to 130 million people according to most government estimates. So how many were actually enrolled in the PCIP program?  At its peak, there were never more than 114, 959 enrollees.  So the entire US health system was re-arranged to accommodate a little more than 100,000 people.  Interestingly 78% of PCIP spending went to only four conditions, cancer, heart and circulatory diseases, post-surgical care, and joint diseases.

So there is a major gap between pre-existing conditions, the propaganda talking point, and pre-existing conditions, the actual policy issue.  And these lead me to notice some curious conservative commentary on the issue.  Prior to the House vote, columnist Anne Coulter wrote a column about the House bill in which she made the remark, “Until the welfare program is decoupled from the insurance market, nothing will work.”  But the biggest player in the conservative pundit class is radio host Rush Limbaugh.  With a 20 million person radio audience, he can move or set the agenda among the right. So what are Rush’s views on pre-existing conditions? He spent quite a bit of time discussing the issue on his show after the House vote, but what caught my eye was this:

“What ought to really happen here is, the simplest way, is to take whatever the percent, 4% who have preexisting conditions and designate them as a special class who are going to have medical expenses covered by some funding mechanism that may be part of the overall bill or not, but don’t commingle these people with the genuine insurance that’s going on elsewhere. ‘Cause then we’re not talking insurance. And it does matter because that’s the way they’re able to convert this into a massive welfare bill while everybody thinks it’s insurance. It’s another sleight of hand.”

To me, it sounds like both commentators are arguing that pre-existing conditions should be handled outside the normal insurance system and covered by a government program.  I think this shows a movement that’s removed from where the House Freedom Caucus is on the issue.  The problem is that no one in the Republican Congress will squarely address the issue.  Putting together a bill to replace Obamacare would be much simpler if they just came out and admitted that people with pre-existing conditions should be served outside of the insurance market.

In other words, a government program.

I had addressed various health reform proposals in general and pre-existing conditions in particular 5 years ago during the Obamacare court fight. At the time I addressed two major issues that needed to be in a future health reform bill:

  1. Tax Credits and deductions to cover the costs of insurance premiums in the individual insurance market.
  2. Some manner of dealing with pre-existing conditions, preferably by some sort of 2nd payer coverage.

I thought I would expand on just how I would cover pre-existing conditions if I were writing the bill.  As stated I would pay charges related to pre-existing conditions with a second payer plan; I’m thinking Medicaid.  But first, some background:

Second payers are plans that pay in addition to regular insurance plans.  People most commonly run across them in Workers Comp and Auto accident issues.  For example, you’re in a car accident, and are taken to the emergency room.  Normally an emergency room visit and associated treatment and tests would be paid by your regular health insurance, but because you have auto insurance and in an auto accident, your auto insurance would be billed first.  The auto insurance pays whatever they are contracted to pay in those circumstances, and the bill goes to your health insurance, which pays whatever it’s contracted to pay minus what was paid by the auto insurance.

Now years ago, some HMO plans would pay for pre-existing conditions, but not right away.  You are a new member on an HMO plan, but you have diabetes.  You could use your insurance for any medical condition except the procedure codes and diagnosis’s associated with diabetes for a period of time, either a year or two years depending on the plan.  After that period was over the HMO would start picking up the costs of diabetic treatment.  This way, the health plan didn’t immediately go into the hole over a brand new member who brings expensive health issues to the plan.  Obviously, this isn’t great at all if you have diabetes because it means you are paying for all of your diabetic treatment and medicines out of pocket until your waiting period was over.  For many however, it was better than no insurance at all.

So how would my plan work?

When you sign up for a health plan on the individual health insurance market in your state, part of the application process is identifying if you have a pre-existing condition.  If so, you are automatically signed up in your state’s Pre-existing Medicaid plan.  This is a secondary payer that only pays if during your first two years in your health plan (or whatever time period is arrived at) you have charges related to your pre-existing condition.  So, let’s say you have heart disease as a pre-existing condition, you go to the doctor for some issue related to that, the doctor files insurance like normal, and it goes to your insurance company.

Since you’re in the first two years of your health plan with this insurance company, and the procedure codes and diagnosis codes are related to your known pre-existing condition, your insurance company denies the claim but then sends it to your state Medicaid, which processes and pays the claim.  For you, the process is seamless, your insurance company gets out of paying charges, and Medicaid pays the doctor.

So, why do I think this is better than the currently proposed high risk pools in the AHCA?

First, we don’t know what the costs are going to be and who is going to need help.  That was the problem with the Obamacare PCIP; far fewer people signed up than expected, but it cost way more per person than expected when they did sign up. So there are a lot of unknown costs associated with this.

Secondly, under high risk pools there seems to me a thin line between subsidizing patients with pre-existing conditions and subsidizing health insurance company profits.  Are the insurance companies just going to present a bill to the high risk pools and they will just pay no matter what?  Who knows?  There isn’t any transparency in knowing what you’re paying for so you can never predict what the costs are.

Third, Medicaid pays out under the cheapest rates available, cheaper than Medicare and far cheaper than private insurance rates.  If the government is going to subsidize pre-existing conditions somehow, why not do it in the way that provides the cheapest rates, and the most transparency? Medicaid will be able to grow a database of all pre-existing conditions, their frequency, and their costs for the private insurance market.

One way or the other, the government will be paying for this. Either the Senate puts together a plan that the President signs, or Obamacare continues to fall apart and a new Democratic Congress will be elected to fix healthcare, and if they do it, given previous experience, it won’t be cheap, transparent, or voluntary.

 

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No Secret Trump Vote

On more than one occasion lately, Rush Limbaugh has been hanging on to the rather thin reed that never mind the polls, there may be a group of secret Trump voters out there who haven’t voted, are not being polled, and may pull through a surprise Brexit like victory for Trump in November.  This is based on a comment that Washington Post Reporter Robert Costa made on the Charlie Rose Show about this alleged hidden Trump vote:

It’s wider than any party.  I mean, it includes some Bernie Sanders supporters. It includes some libertarians.  The most important voter in this movement, uh, when I travel around the country, is the previously disengaged voter.  They’re almost a nonpartisan voter, but they’ve given up not just on the political process, but they’ve disengaged from civic society. They don’t really follow politics. If that’s a real coherent voting block, then Trump — regardless of the polls — will have a shot in November — and regardless of all the mistakes — because that’s a huge block.  There’s so much of this country that rarely, if ever, votes, and if — for some reason — they come to the polls in droves, that changes everything.”

That seems to make sense.  The primaries saw a surge of Republican registration and the largest number of Republican primary voters ever.  So who knows, could there be a group of maybe working class types who dropped out of politics out of disgust years ago but now are raring to go for Trump?  Nobody knows about them because they haven’t been voting, so they have not been polled.  They’re just out there waiting for the moment…

But I think we’ve had enough elections since then to test that proposition and to me, it seems to come up wanting.

Paul Ryan’s Wisconsin primary challenger Paul Nehlen, a pro Trump activist, was easily beaten by Ryan by an astonishing 84% of the vote.

In Arizona John McCain beat challenger Kelli Ward 55% to 35% in spite of Ward linking herself to Trump.

And in Florida, “Little Marco” Rubio, a long time Trump nemesis, beat pro Trump businessman Carlos Beruff 72% to 18%, in spite of joining the race late and being markedly unenthusiastic about returning to the Senate, so much so that he couldn’t even promise to stay for a full 6 year term.  Beruff put himself squarely in the Trump corner. Interestingly, the Republican Senate primary race had 3 Hispanics and 1 African American; no WASPs to be seen.

But the point is that if there was a secret Trump vote, there was ample opportunity for them to show and support the candidates who were counting on Trump coattails to win their races.

They didn’t show, so it’s possible they don’t exist.

 

 

 

Interesting Reads on the Republican Civil War

The Republican Civil War still rages on. National Review’s Jonah Goldberg inspired his very own hashtag, #NROrevolt, after this article:

No Movement That Embraces Trump Can Call Itself Conservative

Goldberg doesn’t go after Trump, he goes after his own readers who are on the Trump Bandwagon; hence the hashtag and ongoing twitter war.

Goldberg made some points, but the blog The Conservative Treehouse made some pretty deft responses:

An Open Letter to Jonah Goldberg-RE: The GOP And Donald Trump

I don’t know who blogger Sundance is, but he or she made some good points.  I would urge Jonah to read it, if he has internet access in whatever undisclosed location he’s at.

As a columnist, I rather like Jonah Goldberg, he’s a witty writer and is the author of probably one of the top 20 must reads of modern conservatism, Liberal Fascism.  However he is strictly a Blue Pill Conservative.  He doesn’t get it.

However there is a chance that someday Goldberg will choose the red pill.  I can’t say the same for Wall Street Journal foreign affairs columnist Bret Stephens. Stephens took on the Trumpocalypse right out of the gate in this piece:

The Donald and the Demagogues

This is how Stephens opens up on the very first line, “If by now you don’t find Donald Trump appalling, you’re appalling.”

And then he proceeds to get nasty. Stephen’s article even got the Rush Limbaugh treatment.  Limbaugh read aloud excerpts from Stephen’s article; apparently in disbelief that one conservative was rounding up dissenters and burning them at the stake. Although far more vicious, Stephen’s article inspired far less reaction than Goldberg’s ( sorry Bret, no hashtag for you) since if you’re a Donald Trump fan, you’ve probably regarded the Wall Street Journal editorial positions as in the enemy camp for a long time.

Old establishment hands still seem to think that Trump will flame out long before the candidates start racking up delegates, and by the time we get to the convention, all will be forgiven and everyone will fall back in line with the generic Republican candidate to defeat the generic Democratic candidate.

Only I’m not so sure.  What’s going on within the Republican Party is unprecedented in my lifetime, and yes, I’m including the Tea Party revolt and Perot’s Reform Party.  We may be seeing a replay of the fall of the Whig Party.

 

Free Speech Thoughts by Bill Maher

The post I wrote last week felt naggingly incomplete to me for some reason.  My purpose was to note that President Obama shouldn’t have gone to the Paris march since he of course wasn’t “Charlie” and had a record of being critical of satire aimed at Islam.  And also to note the irony that the world leaders who did show up at the march were not “Charlie” either.  They came from governments that restricted free speech in one way or the other.

It was another grim reminder on how rights can be taken for granted at the same time they are being quietly taken apart.  And this brings me to Bill Maher.

Maher isn’t in any way a favorite of mine, and the last time I watched him with any regularity he had a show on ABC.  Hey I wonder whatever happened to that…  But for someone who is part of the American left in the 21st Century, he still retains a little of the old 20th Century liberal in him.  Gather round children, because you may not believe it, but there was a time when liberals actually favored free speech, even when it wasn’t politically correct!  Even when they opposed the message!  I know, it’s hard to believe huh?

Of course Maher has had more reason than most liberals to care about freedom of expression as a concept, rather than merely as an obstacle that still allows enemies of the left to voice their opinions.  Just a few months ago he was heavily protested by his fellow leftists at a speaking engagement at UC Berkeley.

So it was not quite surprising when I ran across a Daily Caller story about Maher.  The story, written by Daily Caller writer Chuck Ross (who must be single handedly producing ¾ of the Caller’s content), was taken from Maher’s show Real Time in which he criticized  a group trying to organize a boycott of sponsors of the Rush Limbaugh show.  That’s what old time 20th Century liberals would do; defend, in Voltaire-like fashion, speech they hate.  I think Maher would much rather be on the attack Rush side than on the defense, but he’s mad at official liberalism right now so he’s firing back. Wait until he starts defending Palin….

The problem with Maher is that his liberalism hasn’t really evolved since the 1970’s. Liberals used to really care about free speech, and took seriously the Voltarian maxim that I may not agree with what you say, but I’ll defend to the death your right to say it. But that’s when they perceived themselves as the underdogs against “the establishment.” Now of course, they are the establishment. And guess what? They don’t like free speech. That’s why they want to regulate the internet, regulate political speech, and that’s why they’ve been pushing the doctrine of political correctness. Whatever speech they can’t make illegal, they want to make it unacceptable.

I’ve been surprised just how quickly the left has abandoned free speech.  Social Justice and Identity politics will not compromise with the Bill of Rights.  They demand total allegiance.

Maher is a dinosaur, and when his kind passes over to…well nothingness since he’s an atheist, the only defenders of free speech will be on the right.

 

Democrats losing the White vote?

Just a few more notes on the elections.

In my last post I started out with this:

Rush Limbaugh was in full on denial mode today, bragging that yesterday’s election result meant that the American people soundly rejected liberalism.  Nu-uh.  All it means is that civic minded Republican voters are more likely to turn out to vote during mid-term elections than young people who only know about the President and not much else…And that will be obvious in 2016 when Republicans, who will have more Senate seats to defend than Democrats, lose the Senate gains they’ve just won.

Just to elaborate on that point a bit, if I were to guess right now, I would guess the electorate would swing right back into the Democratic camp in 2016. There is a big difference between the number of people who show up to vote in the mid-terms and those who show up in Presidential years. Based on the numbers I’ve seen this morning, turn out for this year was even lower than in 2010, which was another big Republican year. So you have a 76 million voter turnout for this year, but in 2012 you had 129 million voters.

That’s about a 50 million voter difference between the midterms and the Presidential voting years. So I suspect GOP gains will be washed away in 2016; particularly since there will be more Republican Senate seats to defend then Democratic ones that year. So all of the Republican high fiving will turn to bitter salty tears two years from now, while the current Democratic rage will turn to Democratic gloating.

And demography continues its relentless march,

But I did stumble across a mind blowing revelation, and hat tip to the Parapundit blog for bringing this to my attention, but according to the New York Times, Democrats have not won the white woman vote since 1992.

Where the white women at?

Apparently trending to the GOP.  And I am surprised that I didn’t know that before now.  For decades I’ve been hearing about the GOP’s gender gap, and I knew it was a phony issue.  I mean overall, if your numbers are down for the woman’s vote, the inverse of that is that the numbers are up for the male vote.  However the media doesn’t frame the question that way.  Why can’t Democrats attract Male votes?  Nobody cares about that although the issue is just as real for the Democrats as any alleged female gender gap for the Republicans,  However there is a resistance in the media to accepting that simple truth, no matter how obvious it is.  Certainly that was the case in reference to the Texas Governor’s race in which a Salon writer regards math showing that Davis didn’t win the female vote as racist. White women stayed away from her.

And whites in general are slowly but surely abandoning the Democrats.  An AP article made this point in an exit poll study:

Across 21 states where Senate races were exit polled, whites broke for the Republican by a significant margin in all but four… 

The shift is particularly acute in the South, where some of the last white Democrats in the House of Representatives lost their seats on Tuesday.

In North Carolina, Sen. Kay Hagan carried just 33 percent of the white vote

In Louisiana, Mary Landrieu captured just 18 percent of the white vote

 Illinois Democratic Senator Dick Durbin captured 43 percent of the white vote in his successful bid for re-election, that’s down 18 points from his support among whites in 2008.

After the 2012 election I wrote a post about this very issue, the gradual re-arranging of the political parties along ethnic and racial lines. Of course I thought then that Democrats still had white women, I didn’t realize that as a group, they had left the Democrats a quarter of a century ago.

How you feel about this I suppose depends on your point of view.  If you are a Democratic strategist, even though turn out failed for the Democrats this year, the long term demographic trends are heartening.  As whites move into a smaller percentage of the electorate, the coalition of everyone else will eventually establish more or less permanent political power.  Although that won’t happen quickly, since whites will still be the single largest group.  They are not exactly fading into that good night just yet.

For me, even though the election was disheartening in a lot of ways, I think presages the end of a modern political democracy and voting based on issues into the realignment of parties drawn along ethnic, racial, and religious lines.  In other words, we’ll become like every other 3rd world crap hole country in which issues are irrelevant, only your tribe matters. To me, that’s a sad end for the American experiment.

 

What the New Republican Majority Could Do on Immigration

Rush Limbaugh was in full on denial mode today, bragging that yesterday’s election result meant that the American people soundly rejected liberalism.  Nu-uh.  All it means is that civic minded Republican voters are more likely to turn out to vote during mid-term elections than young people who only know about the President and not much else.  Here in the State of Florida, the purpose behind John Morgan’s Medical Marijuana amendment 2 was to draw in young voters to pull in Democratic votes to put his lickspittle, Charlie Crist, into the governor’s mansion.  Close, but no cigar; or more appropriately, no bong.  Crist and the Medical Marijuana amendment failed by a hair.  Based on an informal survey of my son’s friends, the spirit was willing, but the future time orientation for young people required for registering to vote before the deadline was weak.  If it wasn’t for those darn kids…

glum Obama

And that will be obvious in 2016 when Republicans, who will have more Senate seats to defend than Democrats, lose the Senate gains they’ve just won.  But that’s then.  What about 2015?

One of the most currently divisive issues within the Republican Party is immigration. Half the party agrees with the most extreme Democrats that there really shouldn’t be any barriers to anyone coming to our shores; for different reasons of course.  The Democrats want a poor, uneducated, unskilled mass that will be dependent on them and provide a reliable voting bloc for generations.  The Republicans are split between death wish libertarians who just don’t see a problem with allowing 500 million foreigners to swamp the country, making it resemble Old Calcutta, and Wall Street Journal and Chamber of Commerce types who feel that worker wages are too high if they top a dollar an hour.

Think I’m kidding?  A Silicon Valley tech company was recently fined for actually flying some Indian tech workers from India to the US, paying them $1.21 an hour (the same rate they were paid in India as contractors) and forced them to work 120 hours a week.  That’s an absurdly egregious crime, and rather than mere fines, someone should be facing jail time.  But that’s the future “immigration reform” backers have in store for all of us if they get their way.

That’s why Silicon Valley is spending so much to push immigration reform.  They’ve already spent 50 million dollars on immigration reform lobbying.  Why?  If they get their way, it’s worth it. So it would really be a good strategic move on the part of Republicans to separate the money and lobbying of Silicon Valley from the Democrats, who want poor, ignorant vote fodder forever, and Open Borders Republicans who want declining wage rates stomping on our face forever.  From the Republican Party  perspective, an immigration reform bill along the lines of last year’s Senate bill 744 would split the Republican Party, perhaps permanently. Establishment Republicans may think they want to drive conservatives out of the party, but they wouldn’t like the results of a Republican Party that would no longer be able to win elections in Red States.

But there is a work around to avoid that sort of Republican Party Götterdämmerung.  In 2012 the Republican House tried to get a bill through Congress that would grant 55,000 green cards a year to foreign Doctorate and Masters level graduates.  It wouldn’t have increased immigration numbers since the slots would have been taken from the Diversity Lottery, one of the dumbest immigration programs ever. The bill passed the House and languished in the Senate, since Harry Reid wasn’t interested in bringing any bills up for a vote unless it was something that President Obama specifically wanted to sign.

But starting in 2015, Harry Reid goes back to the bench. With Republicans in control of the Senate and the House, Harry Reid can’t be Obama’s pocket veto anymore.  President Obama will actually have bills arrive on his desk that he will have to actually make decisions on.  He will no longer be able to have Harry Reid vote “present” for him.

Of course the ball will then be in the President’s court.  He can veto the bill, and thereby veto something that his Silicon Valley supporters really want, or sign it, and therefore removing them from the current amnesty coalition.  If Silicon Valley can be tossed a bone to get them separated from the Democrats mass amnesty coalition, it will also separate them both from the lobbying and money they provide, but also one of the phony reasons given for the need for “immigration reform,” the STEM Worker shortage myth. Republican pro-Amnesty warhorses like John McCain might recognize the trap, since the entire purpose of immigration reform isn’t really about STEM workers, border security, or anything else claimed about it other than amnesty for illegals.  On the other hand, new Senate leader Mitch McConnell, who isn’t a pro-amnesty warhorse, might prefer a united Republican Party rather than one fractured along amnesty lines.

I would prefer that myself.

Tea Party Defeats Itself

Just like with the Fiscal Cliff, the House drove us right to the brink until the Senate grabbed hold of the steering wheel, with the news that the Senate has put together a deal to end the government shut down, at least for a while.

As I predicted two months ago, there was no plan, nor any strategy for using the budget CR to defund Obamacare. Everything that happened, from the media spin, to plummeting poll numbers, to final defeat was all perfectly predictable.  There was never any reason that President Obama would negotiate.  He was never going to negotiate on defunding Obamacare. In fact, it’s obvious that he would have been perfectly willing to let us go right through the debt ceiling.  In fact, that could have worked to his advantage.  Any economic upheaval that would have been brought about by stopping the government’s ability to borrow more money could be blamed on the Republicans.  The 2016 campaign slogans write themselves.  Republicans broke the economy, Obama came in and fixed it, and Republicans broke it again.  Are you voting for the breakers or the fixers?

The only thing not predictable was how poorly the Obama administration bungled their handling of the shut down.  Between Harry Reid’s War on Cancer Kids to the administration’s fake and unnecessary closing of the nation’s monuments and other static displays that are normally opened 24/7 without being manned anyway, including the World War II Memorial; which lead to the unpleasant sight of Park Police strong arming elderly national heroes. How badly have you bungled when you pick a fight with cancer kids and World War II veterans in the same week?

Even the administration’s high fiving themselves on the fact that they were “winning” didn’t make them look too smug, since they were in fact winningConsidering that a government shutdown could only help the administration, there was really no way for them to lose, and that’s what irritates me the most; the Tea Party picked a fight in which there was no option that would have allowed them to win.

Although Ted Cruz is given most of the credit/blame for this debacle, I think a good portion of that has to go to talk radio.  Senators Cruz and Lee have appeared on Hannity multiple times talking up their “Don’t Fund it” strategy, but they never exactly explained how the strategy was going to actually achieve its goal of defunding Obamacare.  At no time did Hannity or Rush, who also was in favor of charging this windmill, question how this was supposed to succeed.  That’s a question I’ve been asking for two months and the reason I never got an answer is because there never was an answer.  Meanwhile talk radio egged it on.  On September 25th Hannity had Rand Paul on as a guest, who explained to Hannity that there was no mathematical way there would be votes to defund Obamacare.  Hannity seemed stunned and surprised that Rand couldn’t insure this strategy would work.  As recently as October 3rd, Rush was insisting that the Democrats were imploding on the issue.

The only thing that imploded was the Republican chances of winning the Senate in 2014.