Monday, March 20, 2017

Trump at the Two Month Mark: "The S***show Won't Be Playing Out for the Full Four Years."

My thanks to my friend Ray Abruzzi for the tweet that gave me today's subtitle. It came in a post that linked to one of the many, many, many news stories filed today after FBI Director James Comey confirmed that the FBI was investigating the Trump campaign's collusion with Russian hackers during the 2016 U.S. Presidential campaign.

I'm not sure how that revelation can lead to anything other than a special prosecutor, though I have to admit that I have thus far underestimated the Republican Party's determination to pretend that they can't see the parts of this scandal that played out in plain sight during the 2016 election.

We seem to be plunging quickly into prime Watergate territory despite the best efforts of the US Congress to avoid the inevitable. How it all ends is anybody's guess. About the only thing that has surprised me thus far is the sheer ineptitude of the Trump gang. Although I expected the malevolence and untruthfulness of the Trump Administration, the incompetence has fallen below even my low expectations.

Here's my best guess about what may really will matter as we head down this path:

1. Trump's popularity continues to fall. His approval rating is down to 39% in the Gallup poll and 42.6% in the compendium of polls. Beyond being unprecedented territory for a newly elected president, some historic lows are not too far from here. This matters because the Congressional GOP will eventually have to decide if their agenda faces a larger threat from internal divisiveness -- which will certainly increase if they impeach Trump -- or from voter fury in the 2018 election. Most Republican voters still back Trump, but that number is falling, too.

Thus far the Republicans in Congress are focused on unity, but that could change quickly as 2018 looms or if GOP agenda items like the repeal of the ACA falter because of the distractions or because of Trump himself. Mike Pence will sign their bills just as happily, if not more happily,. It sounds as if an increasing number of GOP Congressmen are starting to admit off the record that this would be fine with them.

1A. Whatever shreds of credibility Trump used to have seem to be fading away. The true diehards who never raise their heads from the Breitbart/Fox/InfoWars/Limbaugh fever pits may not see it, but the rest of America does. This will be very important in media coverage of this scandal as we progress.

2. New revelations: There's nothing like new news to keep a scandal growing. It seems that new information comes forth nearly every day. As reporters keep digging, they keep turning up evidence that increasingly tie Trump's campaign staff to Russian hackers. This continuing drip, drip, drip of information is what forced the House Intelligence Committee to hold today's hearing. The drip, drip, drip seems likely to continue and to continue to force action.

And at some point the FBI will release the results of their investigation.

3. Concrete evidence that directly ties Trump to the actions of his staff: At this point it seems clear that Trump's campaign staff colluded with Russian hackers, though many of the details are still a bit muddled and hidden. Trump seems unlikely to have issued written orders to collude with the Russians, so it will likely take either testimony or a recorded conversation to provide the smoking gun. Trump's fear of concrete evidence coming out is likely behind is bizarre charges that Obama and/or British Intelligence tapped his wires during the campaign. That accusation feels like the sort of weirdly specific charge issued by a paranoid and guilty mind.

4. Will somebody cut a deal? There's a lot of money changing hands right now to try to secure loyalty. Among the former Trump campaign staffers who haven't been able to get a security clearance for a White House gig it's hard to find one who isn't on a foreign payroll right now. But the FBI is pretty good at finding a wedge. Taking the fall and a long prison term sounds romantic in gangster fiction, but it plays out a lot differently when crony crooks face the option of hard time. Heck, given the rate at which Russian diplomats linked to this scandal seem to be dying premature deaths, the witness protection program may soon start to look pretty good.

So, what next?

Beats me. This is an unstable situation that continues to escalate. But the FBI moves at its own pace, so how quickly it comes to a true head is really hard to predict. Maybe they keep grinding out progress and get to the top eventually. Or maybe the FBI is only able to pin this on a fall guy like Roger Stone, and things ramp down eventually.

The betting odds that Trump gets impeached and removed from keep dropping -- now down to 10/11 at Ladbroke's. The odds seem likely to drop again after today's hearing.

That's worth repeating for emphasis. Two months into his first term a President whose party also controls Congress is now more than a 50-50 bet to be impeached and removed from office in his first term.

There's lots else that we could talk about: the lying, the more lying, the lying about the lies, the abandonment of his promises to working-class Americans about the sort of health-care reform he'd support, the myriad foreign policy blunders. But as I look around at the big picture today, it seems to me that the most astonishing thing is that the legal mechanisms for removing him from office are already in motion, despite the best attempts of the party that controls the White House and the Congress to stop them.

I expected a Trump presidency to be historically bad, but I didn't expect things to go downhill so quickly. Honest to Pete, we're just two months removed from the Inauguration and we're already hip deep in FBI and Congressional investigations.

As I quoted in my subtitle, this disaster can't possibly last four years. It just can't.

Tuesday, March 14, 2017

Health Care: how did we get here? Where are we going?

If you're wondering who socialized medicine in the United States, it wasn't Barack Obama. It was Ronald Reagan.

In 1986 Reagan signed the Emergency Medical Treatment and Active Labor Act, which prohibited hospitals from refusing to admit or dumping uninsured patients who arrived in emergency rooms.

This was a good, humane idea. Some hospitals were literally putting people with heart attacks and stab wounds out by the curb to die.

But it also created a spiral in which an increasing number of the uninsured showed up at emergency rooms for treatment either for minor issues that weren't really emergencies, or for major emergencies that would have been much less costly to treat had they been treated earlier.

Literally leaving people to die at the curb is unpleasant, but it is a good deal cheaper than actually treating them.  And aside from the extra costs of emergency room services, the amounts charged to uninsured patients for treatments is often much larger than the amount charged to insured patients for the exact same treatment. This is because insured patients are covered by contracts with prices negotiated by their insurers. Not surprisingly, bill collections against these uninsured folks for these inflated debts generally resulted in poverty, bankruptcies, and very little actual money collected -- per the well established economic dictum, "You can't squeeze blood from a stone."

It's also worth noting here that "poor" in the health insurance debate doesn't necessarily mean "destitute, homeless, on welfare, etc." Most of the poor in this context were the working poor: people working full- or near-full-time jobs that didn't provide affordable health insurance. The truly destitute often were at least partially covered by Medicaid. The working poor were often left out in the cold.

Still, somebody had to pay the bills. One of the reasons the cost of insurance for the insured rose much faster than inflation was because our health care system had to absorb these additional overhead costs.

There were many other contributors to the rapid rise in health insurance costs before the Affordable Care Act (ACA) was adopted in 2010: increasing use of technology, pharmaceutical costs, malpractice lawsuit costs (themselves made worse by the spiraling cost of health care itself), forcing the sick out of the insured pool due to preexisting conditions, etc. But the basic math of covering the poorest people in America in the most expensive way possible is immutable. Eventually, more people become uninsured and the people with insurance have to pay more to cover their costs.

Ultimately, you face three options:

1) Remove emergency-room care. Leave the working poor, the elderly and the truly destitute to die in the streets.

2) Cover those people with some sort of jury-rigged private market and government healthcare approach that balances things like requirements that individuals carry health insurance, financial support for policies that cover the poor, and requirements that insurance companies accept all comers.

3) Expand government insurance like Medicaid and Medicare to cover all of the uninsured. Or perhaps even expand it further to become basic insurance for all Americans.

Ronald Reagan and the US Congress rejected option #1 in 1986 for good reasons. If I need to explain them to you, you probably need to take a deep look inside your dark soul.

It's worth noting that Republicans do have a lot of good reasons to seek a better health care system. Spiraling health care costs are a genuine drag on businesses because of our employer-based insurance system. Those uncontrolled costs also contribute greatly to increased government costs. A better health care system that delivered better (or at least similar) results for less money would be of great benefit to a party that is in favor of business owners and reduced government spending.

Option #2 emerged as the conservative Republican alternative for the emerging health care crisis because #3 -- directly expanding the government safety net -- was at complete odds with a conservative political philosophy. So, creating an alternative based on the private market was kicked around for years.

Then, much to everybody's surprise, Mitt Romney managed to implement exactly that in Massachusetts in 2006 while he was governor. And it sorta worked. It at least made a bad situation better.

After Obama was elected in 2008 he decided to take that Republican approach and expand it to the federal level. This worked in one way, the Affordable Care Act (aka Obamacare) was passed in 2010 and it has succeeded in greatly expanding coverage and slowing the rate of growth of health-care costs. It didn't do these things as completely or quickly as something like a full expansion of Medicaid and Medicare would have. It was also less completely disruptive to the existing health-care model, and that had genuine benefit for a country still suffering from the Great Recession.

There was, however, an unexpected side-effect. The Republican Party's leadership decided that they would benefit from outright opposition to Obama on all things. The debate over the ACA became the prime battlefield for that proposition. To Obama's credit he managed to secure enough Democratic support for a proposal that originally came from Republicans to overcome the unified opposition of the GOP. The Republicans, however, were right that their opposition would energize their base. That led to their Tea-Party fueled victories in the 2010 elections and the subsequent gerrymanders that established political dominance for them in state legislatures and the US House ever since.

Thus was the frame of the debate for the last six years or seven years set, with Democrats uncomfortably but unanimously supporting what most of them thought was a flawed half-measure and Republicans unanimously blasting the ACA's very existence and claiming they could do better without ever producing a genuine proposal. To compound the problem, many Republican controlled states refused to implement the expanded Medicaid coverage, leaving many Americans needlessly uncovered. In the meantime, some genuine improvements to the ACA that could have been made were ground to dust beneath the tracks of the Washington, DC, gridlock of 2011-2016.

So, why did the GOP never produce a genuine health-care proposal of their own in all that time?

Most likely because the Democrats had already passed their proposal. Obamacare was never anything more than federalized Romneycare. If you thought Mitt Romney looked uncomfortable in 2012 trying to explain how he completely opposed a health care structure that he fathered, that's why.

Which brings us to 2017 with the GOP finally in charge of Congress and the White House. What has Paul Ryan and the GOP produced? A bill that makes the situation that existed in 2009 worse, and that now has the Congressional Budget Office (CBO) analysis to prove it. In exchange for throwing tens of millions of people off health care and greatly increasing insurance costs for most other Americans, it offers up massive tax cuts for millionaires and billionaires. As just one note among many items in the report, the CBO does find $3 billion potential deficit reduction for Social Security costs because they estimate that between 17,000 and 29,000 Americans will die needless premature deaths because they will not have access to health care.

I would say this means the GOP's long con on health care policy is finally exposed and this bill is dead, but with Ryan, McConnell, and Trump all on board I wouldn't be in the least surprised if they still try to ram some form of it through. More likely, though, it sputters out somewhere between the House and the Senate, after which the Republican Party continues to loudly blame Democrats for all things related to health care.

We shall see. Darned if I can accurately predict anything politically these days.

What might I like to see for health care in the US? Well, it seems to me that the most useful approach would probably be incremental: maybe an expansion of Medicaid as a bottom-level medical benefit for everybody, dropping the Medicare eligibility age to 60 or 55 to bring healthier folks into that pool, while also providing a higher-level of health care coverage for those who can afford supplemental insurance. It probably doesn't move all the way to a true single-payer system as is seen in other industrialized nations. But somewhere in there might be a recipe for building on what we already have -- keeping some genuine market mechanisms for improving efficiency and quality while not kicking tens of millions of Americans to the side to be bankrupted before dying in the streets.

Of course, that sort of thing would take some level of genuine fact-based policy work and bipartisan cooperation to implement. Those are qualities sadly lacking in Washington, DC, at the moment.

But even that may change one day. And the problem will still be with us for a long time to come.