tag:theconversation.com,2011:/global/topics/paul-ryan-3575/articlesPaul Ryan – The Conversation2019-01-07T00:19:22Ztag:theconversation.com,2011:article/1094172019-01-07T00:19:22Z2019-01-07T00:19:22ZWould bringing back pork-barrel spending end government shutdowns?<figure><img src="https://images.theconversation.com/files/252593/original/file-20190106-32136-9fnjuw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Members of Congress, including House Speaker Nancy Pelosi of Calif., second from right, walk toward the Capitol building, Jan. 4, 2019. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/New-Congress/5e0e6f888c6d4b92b6181165b2340737/2/0">AP/Andrew Harnik</a></span></figcaption></figure><p>For eight years, Congress has banned the use of earmarks, otherwise known as “pork-barrel spending.” Earmarks paid for pet projects of legislators back in their districts, as a way of encouraging those officials’ votes for a spending bill. </p>
<p>But earmarks were seen by many members of the public as wasteful and distasteful. Even some lawmakers didn’t like them. </p>
<p>“Earmarks are the gateway drug to spending addiction,” <a href="https://books.google.com/books?id=uof0TefzQRMC&lpg=PR4-IA65&ots=hsDaNcni5r&dq=%E2%80%9CEarmarks%20are%20the%20gateway%20drug%20to%20spending%20addiction.%E2%80%9D&pg=PR4-IA65#v=onepage&q=%E2%80%9CEarmarks%20are%20the%20gateway%20drug%20to%20spending%20addiction.%E2%80%9D&f=false">said Sen. Tom Coburn, a Republican from Oklahoma,</a> in 2007.</p>
<p>But now, in the middle of one of the longest federal government shutdowns on record, Rep. Nita Lowey, the new chairwoman of the powerful House Appropriations Committee, made a bold statement: She wants to bring back pork-barrel spending in order to make passing appropriations bills easier.</p>
<p>“I would be supportive of earmarks,” Lowey, a Democrat from New York, <a href="https://www.politico.com/newsletters/playbook/2019/01/05/shutdown-negotiations-drag-on-371052">told Politico</a>. “I think there is a way to do it.”</p>
<h2>Greasing the wheels – maybe</h2>
<p>Earmarks would not have solved the current government shutdown, which is the result of an impasse between congressional Democrats and President Trump over funding the president’s border wall. </p>
<p>But Lowey’s not alone in her concern with Congress’ inability to pass spending bills on schedule. That difficulty, which has ended in several government shutdowns in the last decade, has produced unrelenting criticism by commentators and members of Congress alike. </p>
<p>A return to earmarking – for <a href="https://www.cagw.org/content/pig-book-2010">projects ranging</a> from new bridges to museum funding to renewable energy research, tailored for individual members’ districts – would require lifting a <a href="https://www.washingtonpost.com/investigations/what-is-an-earmark/2012/01/27/gIQAK6HGvQ_story.html?utm_term=.4d20f6eae67f">2011 moratorium</a> imposed on the practice.</p>
<p>I have <a href="http://www.cambridge.org/us/academic/subjects/politics-international-relations/american-government-politics-and-policy/greasing-wheels-using-pork-barrel-projects-build-majority-coalitions-congress?format=PB&isbn=9780521545327#iRqCLBv6sXpLtGJr.97">studied</a> the effect of pork-barrel spending on passing spending bills. Although earmarks are worth reconsidering as a way of greasing the legislative wheels, I would argue that the case for them is mixed.</p>
<p>Pro-earmark arguments have come from <a href="https://www.pbs.org/newshour/politics/the-bipartisan-movement-to-bring-back-earmarks-in-congress">both parties</a>. The supporters include Sens. Patty Murray, D-Wash., and Susan Collins, R-Maine, as well as <a href="https://www.washingtonpost.com/news/monkey-cage/wp/2018/01/12/trump-just-praised-earmarks-heres-what-the-fuss-is-about/?utm_term=.c59c812e7fb8">President Trump</a>. </p>
<p>Simultaneously, pressure from House Republicans led former Speaker Paul Ryan <a href="https://www.c-span.org/video/?439801-1/house-rules-committee-holds-hearing-earmarks">to allow hearings</a> to consider ending the 2011 earmark moratorium. </p>
<p>Prior to 2011, these earmarks were, with a few exceptions, regularly, and until 2006, in increasingly <a href="https://www.cagw.org/content/pig-book-2010#historical_trends">large numbers,</a> put into appropriations bills as well as highway reauthorizations to help smooth the way to passage. </p>
<h2>Pork helps move things along</h2>
<p>My own <a href="http://www.cambridge.org/us/academic/subjects/politics-international-relations/american-government-politics-and-policy/greasing-wheels-using-pork-barrel-projects-build-majority-coalitions-congress?format=PB&isbn=9780521545327#iRqCLBv6sXpLtGJr.97">research</a>, as well as that of <a href="https://www.jstor.org/stable/3186129?seq=1#page_scan_tab_contents/">Frances Lee of the University of Maryland</a>, shows that earmarks helped transportation committee leaders pass three massive highway bills, overcoming significant policy controversies surrounding each bill. I also found that earmarks were often helpful in passing appropriations bills. </p>
<p>Nevertheless, to opponents, earmarks remain pork-barrel projects that are rife with waste and reek of corruption. Former Sen. Clare McCaskill, a Missouri Democrat, called earmarks “the Washington swamp creature that <a href="https://www.toomey.senate.gov/?p=news&id=2097">just never seems to die.”</a> </p>
<p>To supporters, on the other hand, earmarks are a legitimate use of Congress’ constitutionally mandated <a href="https://books.google.com/books/about/Cheese_Factories_on_the_Moon.html?id=xwILSgAACAAJ">power of the purse</a>, which, not incidentally, may help members’ political careers.</p>
<p>Earmark proponents say a return to the practice could remedy the long-running difficulty of passing appropriations bills in a carefully considered, transparent manner. </p>
<h2>What did we spend that money for?</h2>
<p>In the normal appropriations process, Congress would pass 12 individual spending bills each year, a process designed to give members of Congress a chance to examine the spending in each bill before voting. </p>
<p>The reality is far different. </p>
<p><a href="http://www.pewresearch.org/fact-tank/2018/01/16/congress-has-long-struggled-to-pass-spending-bills-on-time/">Data compiled</a> by the Pew Research Center show that between the 2011 earmark moratorium and fiscal year 2018, only one individual appropriations bill was enacted, rather than the 84 appropriations bills Congress should have passed. </p>
<p>The record was somewhat better last year, when five of the 12 bills became law. The remaining seven Fiscal Year 2019 appropriations bills have been held up by the president’s insistence on funding for a border wall in the Homeland Security bill.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/211762/original/file-20180323-54869-1e7i2ow.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/211762/original/file-20180323-54869-1e7i2ow.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=326&fit=crop&dpr=1 600w, https://images.theconversation.com/files/211762/original/file-20180323-54869-1e7i2ow.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=326&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/211762/original/file-20180323-54869-1e7i2ow.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=326&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/211762/original/file-20180323-54869-1e7i2ow.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=409&fit=crop&dpr=1 754w, https://images.theconversation.com/files/211762/original/file-20180323-54869-1e7i2ow.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=409&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/211762/original/file-20180323-54869-1e7i2ow.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=409&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Pork-barrel spending can help move things along.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>Instead of using the process that encourages careful consideration of individual spending items, Congress has funded government agencies in <a href="http://www.pewresearch.org/fact-tank/2018/01/16/congress-has-long-struggled-to-pass-spending-bills-on-time/">massive omnibus appropriations bills or full-year continuing resolutions</a>. These bills make it virtually impossible for members to know what they are voting for. </p>
<p>This breakdown in the appropriations process coincides neatly with the earmark moratorium. </p>
<p>However, the process did not always go smoothly before the moratorium either. The <a href="https://www.cagw.org/content/pig-book-2010#historical_trends">large increase</a> between 1991 and 2006 in the cost of earmarks, from $3.1 billion to $29 billion, did not ensure the passage of stand-alone appropriations bills.</p>
<p>Would earmarks now help Congress pass appropriations bills? </p>
<p>The evidence is less clear than it is for highway bills. I <a href="http://www.cambridge.org/us/academic/subjects/politics-international-relations/american-government-politics-and-policy/greasing-wheels-using-pork-barrel-projects-build-majority-coalitions-congress?format=PB&isbn=9780521545327#iRqCLBv6sXpLtGJr.97">analyzed</a> a number of Senate appropriations bills from 1994 to 2000; although the political dynamics might be different today, the findings could be helpful for the current conversation about earmarks. </p>
<p>In 1994, when the Democrats controlled Congress, earmarks helped convince senators to vote in support of the positions of the powerful appropriations subcommittee chairs. </p>
<p>After the Republican takeover in 1995, however, earmarks were somewhat less effective. By 2000, with Republicans still in control, earmarks – although growing in number and cost – had no discernible effect on senators’ appropriations votes. </p>
<h2>Partisanship could undermine earmarks’ benefits</h2>
<p>My interviews with committee staff members suggested various reasons for this. Prominent among them, according to one staffer, was the fact that votes were “increasingly … on highly charged substantive policy matters.” Senators needed to vote on those issues in a partisan manner, regardless of earmarks. </p>
<p>Another staffer blamed the failure of leaders to punish disloyal members by removing their earmarks. </p>
<p>That staffer said, “People have no shame. They vote no and take the dough.”</p>
<p>It is difficult to predict how returning to pork-barrel spending would work today. </p>
<p>For earmarks to be effective tools, members who otherwise would oppose the bills on a partisan or ideological basis would have to vote contrary to their own or their party’s preferences. Their willingness to do so would undoubtedly depend partly on the electoral consequences.</p>
<p>As Yale political scientist David Mayhew has <a href="https://yalebooks.yale.edu/book/9780300105872/congress">argued</a>, members believe that bringing benefits to their home district gives them something they can claim credit for, enhancing their chances for re-election. That gives congressional leaders leverage over members’ votes.</p>
<p>The evidence for this effect is nuanced, however. </p>
<p>Earmarks can help members <a href="https://www.sciencedirect.com/science/article/pii/S0176268013000633">win re-election</a>, especially when members <a href="https://www.cambridge.org/core/journals/american-political-science-review/article/how-words-and-money-cultivate-a-personal-vote-the-effect-of-legislator-credit-claiming-on-constituent-credit-allocation/7538BBE494CE31274DAE7F9F2E220F04">claim credit for them</a>. </p>
<p>But there is also evidence that constituents are more likely to reward Democrats than Republicans <a href="https://www.researchgate.net/publication/4935138_Deficits_Democrats_and_Distributive_Benefits_Congressional_Elections_and_the_Pork_Barrel_In_The_1980s">for such benefits</a>. This is not entirely surprising, given that earmarks are consistent with Democrats’ commitment to activist government. For Republicans committed to cutting the cost of government, bringing home earmarks could be painted as hypocritical. </p>
<p>These differences could help explain why I found that earmarks provided leaders with less leverage over members’ votes in Republican-controlled congresses.</p>
<h2>The powerful get more</h2>
<p>At their peak, earmarks amounted to approximately 3 percent of the discretionary budget, the portion that Congress controls, which amounts to about one-third of total federal spending. As a result of earmark reform in 2007, spending on earmarks dropped to 1.3 percent <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1540-6210.2010.02304.x/abstract">of the discretionary budget</a>. In fiscal year 2010, earmarks cost $16.5 billion.</p>
<p>Earmarks are vulnerable to other criticisms, not least of which is the disproportionate share awarded to the districts of the most powerful members, particularly to members and leaders of the appropriations committees. </p>
<p>For example, scholar <a href="http://journals.sagepub.com/doi/abs/10.1177/1532673X15576952">Austin Clemens and his colleagues found</a> that in 2008 and 2009, members of the House Appropriations Committee got 35 percent of all earmarked dollars. That was more than twice what they would have received if earmarks had been equally distributed among all the committee members.</p>
<p>In addition, the majority party gets disproportionately more earmarks than the minority, although the minority gets enough to make it harder for them to use earmarks as a campaign issue. That’s a strategy dubbed “partisan blame avoidance,” <a href="http://www.jstor.org/stable/3088396?seq=1#page_scan_tab_contents">according to Steven J. Balla of George Washington University and his colleagues</a>.</p>
<p>While it is tempting to condemn earmarks as frivolous or corrupt, research paints a more complex picture of their role in the governing process. </p>
<p>As Congress wrestles with the process of passing individual appropriations bills, party leaders may respond by once again allowing earmarks in appropriations bills, winning more votes for spending bills, and protecting some of their own vulnerable members at the polls.</p>
<p><em>This is an updated version of <a href="https://theconversation.com/a-return-to-earmarks-could-grease-the-wheels-in-congress-91811">an article</a> originally published on March 26, 2018.</em></p><img src="https://counter.theconversation.com/content/109417/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Diana Evans is affiliated with
Common Cause in Connecticut </span></em></p>Banned since 2011, pork-barrel spending may well help Congress pass bills on schedule. Now, a powerful Democratic lawmaker said she’d like to resurrect the practice to make passing budgets easier.Diana Evans, Professor of political science, Trinity CollegeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/958272018-05-01T10:41:31Z2018-05-01T10:41:31ZWhy does Congress have a chaplain?<figure><img src="https://images.theconversation.com/files/216882/original/file-20180430-135803-dti43f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Father Patrick Conroy.</span> <span class="attribution"><span class="source">AP Photo/J. Scott Applewhite</span></span></figcaption></figure><p>House speaker Paul Ryan has <a href="https://www.nytimes.com/2018/05/03/us/politics/house-chaplain-resignation.html">reinstated</a> Father Patrick Conroy as chaplain of the House of Representatives. Conroy, who <a href="https://www.nytimes.com/2018/04/27/us/politics/house-chaplain-fired.html">resigned</a> last week, later rescinded his resignation, daring the speaker to <a href="https://static01.nyt.com/files/2018/us/politics/20180304-chaplain-letter.pdf">fire him</a> instead.</p>
<p>We are <a href="http://www.wendycadge.com/">scholars</a> of <a href="http://laurao.people.clemson.edu/">religion and American politics</a> who, with Brandeis Ph.D. candidate Margaret Clendenen Minkin, have written about the <a href="http://www.wendycadge.com/wp-content/uploads/2017/10/Cadge.Olson_.Clendenen.2015.pdf">history and work of congressional chaplains</a>. The present controversy offers a unique opportunity to ask broader questions about what congressional chaplains do and why the U.S. Congress employs them in the first place. </p>
<h2>History of congressional chaplains</h2>
<p>The American tradition of legislative prayer dates to 1774, when <a href="https://chaplain.house.gov/chaplaincy/ChaplainHistoryCRS.pdf">Jacob Duché</a>, the rector of Christ Episcopal Church in Philadelphia, was recruited to offer prayers before the <a href="https://www.history.com/this-day-in-history/first-continental-congress-convenes">First Continental Congress</a>. </p>
<p>After the Constitution was ratified, the U.S. Senate <a href="https://www.senate.gov/artandhistory/history/common/briefing/Senate_Chaplain.htm">selected</a> an Episcopal bishop from New York, Samuel Proovost, as its chaplain in April 1789. </p>
<p>For its part, the House of Representatives chose William Linn, a Philadelphia Presbyterian minister, as its first chaplain in May 1789. Proovost and Linn each received an annual salary of US$500. After Congress moved to Washington, D.C., local clergy took turns leading prayer before the permanent chaplaincies were institutionalized. </p>
<h2>Who are the chaplains today?</h2>
<p>Today, congressional chaplains hold full time, nonpartisan, nonsectarian jobs. They are formal officials of the chamber in which they serve. Each chaplain has a staff and is paid as a level IV executive federal employee: <a href="https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/18Tables/exec/html/EX.aspx">currently $164,200</a>.</p>
<p>The <a href="https://chaplain.house.gov/chaplaincy/ChaplainHistoryCRS.pdf">chaplains</a> offer public prayers at the beginning of each day of congressional business. They also provide pastoral care for members of Congress and others associated with the House and Senate, including staff, police and family members. </p>
<p>It is noteworthy, however, that they <a href="http://www.wendycadge.com/wp-content/uploads/2017/10/Cadge.Olson_.Clendenen.2015.pdf">do not</a> demographically represent the American public, and quite strikingly so. Every congressional chaplain since 1789 has been a Christian man, and of those nearly all have been Protestant. Only one, the current Senate chaplain, Rev. Barry Black, has been a person of color. The only time that Muslim and Hindu chaplains <a href="http://www.wendycadge.com/wp-content/uploads/2017/10/Cadge.Olson_.Clendenen.2015.pdf">have delivered prayers</a> was as one-time guest clergy. It’s the same for women. </p>
<h2>Church-state separation?</h2>
<p>In a nation in which church-state separation is the law of the land, it has long been controversial to have chaplains formally working for the federal government. During the 1850s, Congress received a number of petitions calling for the elimination of the positions. But chaplains remained.</p>
<p>In 1983 a lawsuit led by Ernest Chambers, a member of the Nebraska State Legislature, to end the practice of legislative prayer reached the <a href="https://supreme.justia.com/cases/federal/us/463/783/case.html">U.S. Supreme Court</a>. However, the court decided to defer to historical custom rather than asserting a firm boundary between church and state. </p>
<p>The current controversy, however, is unprecedented. Father Conroy is the first congressional chaplain ever asked to leave office in the middle of a congressional term and certainly the first to rescind his resignation. As this debate continues there are more and more <a href="http://thewashingtonpost.newspaperdirect.com/epaper/viewer.aspx">calls</a> to abandon the practice of having legislative chaplains all together. Perhaps that is the conversation worth having. </p>
<p><em>This is an updated version of an article originally published on May 1, 2018.</em></p><img src="https://counter.theconversation.com/content/95827/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Wendy Cadge receives funding from the Society for the Scientific Study of Religion.</span></em></p><p class="fine-print"><em><span>Laura R. Olson does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Following the controversy over the resignation of House chaplain Patrick Conroy, in this speed read, scholars explain when the tradition of legislative prayer was started and how it has sustained.Wendy Cadge, Professor of Sociology and Women's, Gender and Sexuality Studies, Brandeis UniversityLaura R. Olson, Professor of Political Science, Clemson UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/948842018-04-13T10:43:31Z2018-04-13T10:43:31ZWhat does the speaker of the House do? Here’s what Kevin McCarthy’s successor will have for a job<figure><img src="https://images.theconversation.com/files/502973/original/file-20230103-104784-tn6tqf.jpeg?ixlib=rb-1.1.0&rect=8%2C8%2C5446%2C3712&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Kevin McCarthy, a Republican from California, has fought a battle with conservatives in his party for the speakership.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/house-minority-leader-kevin-mccarthy-speaks-to-reporters-news-photo/1454009418?phrase=Kevin%20McCarthy&adppopup=true">Kevin Dietsch/Getty Images</a></span></figcaption></figure><p><a href="https://www.voanews.com/a/us-presidential-line-of-succession/4674320.html">Second in the line of presidential succession</a> after the vice president, the speaker of the House occupies a central role in our national government. But what is it that a speaker actually does?</p>
<p>Most people think the speakership is a party office. <a href="http://history.house.gov/Institution/Origins-Development/Speaker-of-the-House/">It’s not</a>. The speaker is selected by the full House membership, though the majority party’s voting power ensures that the role is occupied by one of their own. </p>
<h2>From legislation to accounting</h2>
<p>The speaker fills three primary roles. </p>
<p>First, they are the most visible and authoritative spokesperson for the majority party in the House. Speakers articulate an agenda and explain legislative action to other Washington officials as well as the public. They oversee House committee assignments and collaborate with the powerful <a href="https://rules.house.gov/">House Rules Committee</a> to structure floor debate. </p>
<p>Second, the speaker manages business on the floor and navigates legislative rules, structuring House debate in a way that will advantage their legislative priorities. Adherence to strict rules and procedures is necessary to overcome the difficulty of managing a large legislative body like the House of Representatives. </p>
<p>Third, the speaker oversees everything from accounting to procurement for the House. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/214614/original/file-20180412-592-1mxz72s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/214614/original/file-20180412-592-1mxz72s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=1006&fit=crop&dpr=1 600w, https://images.theconversation.com/files/214614/original/file-20180412-592-1mxz72s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=1006&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/214614/original/file-20180412-592-1mxz72s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=1006&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/214614/original/file-20180412-592-1mxz72s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1264&fit=crop&dpr=1 754w, https://images.theconversation.com/files/214614/original/file-20180412-592-1mxz72s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1264&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/214614/original/file-20180412-592-1mxz72s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1264&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Massachusetts Democrat Tip O'Neill, who served as speaker from 1977 to 1987.</span>
<span class="attribution"><span class="source">AP Photo/Steven Senne</span></span>
</figcaption>
</figure>
<h2>Power ebbed and flowed</h2>
<p>During the republic’s early years, the speakership gradually gained power. By 1910, Speaker Joe Cannon had centralized power to such an extent that many of his own party members <a href="http://www.post-gazette.com/opinion/david-shribman/2010/03/14/Getting-rid-of-Uncle-Joe/stories/201003140237">rebelled</a>. Power was redistributed to committees and lower-level party leaders. </p>
<p>By the 1970s, committees had gained such control over legislative outcomes that widespread <a href="https://library.cqpress.com/cqalmanac/document.php?id=cqal75-1210820">reforms</a> were adopted, which shifted power back to the speaker. </p>
<p>From 1977 to 1995, three successive Democratic speakers – <a href="http://history.house.gov/People/Detail/19187">Thomas “Tip” O’Neill</a>, <a href="http://history.house.gov/People/Detail/24127">Jim Wright</a> and <a href="http://history.house.gov/People/Detail/13275">Tom Foley</a> – reinvigorated the speakership. They enlarged the party leadership structure, creating wider networks of loyalty among members of the majority party while strengthening support for their priorities.</p>
<p>Today, the role of the speaker is influenced especially by <a href="https://www.nytimes.com/1994/12/08/us/republicans-seek-sweeping-changes-in-house-s-rules.html">changes instituted by Speaker Newt Gingrich</a>, who took the gavel after the 1994 elections. </p>
<p>Gingrich, a Republican, was overtly partisan in the role. He announced that, <a href="https://www.washingtonpost.com/archive/politics/1998/04/07/the-education-of-newt-gingrich-a-first-person-view-of-events/759593a9-deea-44d8-bde6-7a48e3bf51fc/?utm_term=.273e806f577c">compared with past speakers</a>, he was “essentially a political leader of a grassroots movement seeking to do nothing less than reshape the federal government along with the political culture of the nation.”</p>
<p>Since Gingrich’s tenure, speakers are often criticized as too partisan and too powerful, trampling minority party interests. But this is the nature of the job in today’s Washington. </p>
<p><em>This story was updated to remove outdated information.</em></p><img src="https://counter.theconversation.com/content/94884/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rachel Paine Caufield does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The speaker of the House is the most visible and authoritative spokesperson for the majority party in the House. But their role goes beyond politics to everything from accounting to procurement.Rachel Paine Caufield, Professor of Political Science, Drake UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/922722018-03-15T00:26:03Z2018-03-15T00:26:03ZArticulate US teenagers could finally force action on gun control<p>On Wednesday in the US, <a href="https://www.nytimes.com/2018/03/14/us/school-walkout.html?hp&action=click&pgtype=Homepage&clickSource=story-heading&module=photo-spot-region&region=top-news&WT.nav=top-news">thousands of students left their classrooms</a> in a national day of action <a href="https://www.actionnetwork.org/event_campaigns/enough-national-school-walkout">designed to force political change on gun crime</a>. Following the recent shooting at Marjory Stoneman Douglas High School, this walkout is part of an extraordinary national movement. Young people across the US are doing what countless others have tried and failed to do: using grassroots strategies to take on the powerful gun lobby.</p>
<p>The US has an epidemic of gun crime. Mass shootings <a href="https://www.theguardian.com/us-news/ng-interactive/2017/oct/02/america-mass-shootings-gun-violence">occur every day</a>, and school shootings have become so common that over <a href="https://www.washingtonpost.com/news/answer-sheet/wp/2018/02/20/how-mass-school-shootings-affect-the-education-of-students-who-survive/?utm_term=.6382da2f25e8">170 schools and some 150,000 students have been affected by school-based gun violence since 1999</a>. </p>
<p>Beyond the psychological trauma such attacks inflict, these shootings have a <a href="http://journals.sagepub.com/doi/full/10.3102/0162373715590683">profound effect on academic success rates</a>.</p>
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<p>And yet, in spite of <a href="http://time.com/5167216/americans-gun-control-support-poll-2018/">the overwhelming majority of Americans who want tighter gun control laws</a>, very little is done to stem the presence of guns in schools, or the ability of Americans to access high-powered weaponry with relative ease.</p>
<h2>Policy inertia and the NRA</h2>
<p>The main reason for this inertia is the extraordinary influence of the <a href="https://home.nra.org/">National Rifle Association</a> (NRA). Since it turned to a <a href="https://theconversation.com/how-big-tobacco-gifted-campaigns-of-misdirection-and-misinformation-to-the-gun-lobby-45108">more aggressive lobbying strategy in the 1970s</a>, the NRA has helped <a href="https://www.politico.com/magazine/story/2014/05/nra-guns-second-amendment-106856">redefine the meaning of the 2nd Amendment</a>, bestowed a <a href="https://www.theatlantic.com/politics/archive/2018/02/wayne-lapierres-trumpian-base-strategy/553964/">divine blessing on guns</a>, and <a href="https://edition.cnn.com/2018/02/23/politics/nra-political-money-clout/index.html">bent half of Congress to its will</a>.</p>
<p>The NRA succeeds because it has created powerful (<a href="http://heinonline.org/HOL/LandingPage?handle=hein.journals/tfcl11&div=7&id=&page=">and mostly false or distorted</a>) narratives to support gun use. It deploys familiar tropes to distract from tragedies. When gun-related tragedy hits, NRA-backed politicians call for “thoughts and prayers”. </p>
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<p>The reality of US gun deaths is set against such pro-gun arguments, and each tragedy widens the stark divide between those <a href="http://www.nrafff.com">who associate guns with freedom</a>, and those who see them as <a href="http://time.com/5198721/capitol-gun-death-protest-shoes/">devices for terror</a>. So, when others call for legislative action, as they did following the massacre at Sandy Hook and other mass shootings, the gun lobby scolds them for <a href="http://thehill.com/blogs/blog-briefing-room/news/274461-norquist-accuses-obama-of-politicizing-sandy-hook-school-shooting">“politicising tragedy”</a>.</p>
<p>But murdered kids are political. Sandy Hook exposed the US to the <a href="https://www.wptv.com/news/news-photo-gallery/sandy-hook-victims-names-list-photos-bios-1#id0">faces of erstwhile happy kindergarteners</a>, their lives snuffed out by a disturbed young man with easy access to guns. It’s an all-too-familiar story for Americans and, <a href="https://www.nytimes.com/2016/06/14/upshot/compare-these-gun-death-rates-the-us-is-in-a-different-world.html">by international comparison, a unique one at that</a>.</p>
<p>Yet the resulting push for change soon turned to despair: <a href="http://www.baltimoresun.com/news/opinion/oped/bs-ed-pitts-20150903-story.html">many came to believe</a> that if 26 deaths at an elementary school can’t bring Congress to act, nothing can.</p>
<h2>Gun laws and the possibility of change</h2>
<p>The last last major piece of gun control legislation to pass Congress was the <a href="http://legisworks.org/GPO/STATUTE-108-Pg1796.pdf">federal assault weapons ban</a> in 1994. It was specifically designed to reduce the incidence of mass shootings, and targeted the <a href="https://www.theatlantic.com/politics/archive/2018/02/what-i-saw-treating-the-victims-from-parkland-should-change-the-debate-on-guns/553937/">enhanced killing power of assault rifles</a>. But, under <a href="https://www.factcheck.org/2013/02/did-the-1994-assault-weapons-ban-work/">sustained attack from the gun lobby</a>, the ban expired under its “sunset clause”.</p>
<p>Since then, the one major piece of gun legislation in the US, in spite of the national rise in mass and school shootings, has been an <a href="https://www.gpo.gov/fdsys/pkg/STATUTE-119/pdf/STATUTE-119-Pg2095.pdf">act designed to protect gun manufacturers in 2005</a>.</p>
<p>Now, for the first time in decades, there is a real possibility that some gun controls might be implemented. The NRA, as well as numerous politicians associated with it, are facing significant pressure to act. </p>
<p>Recent news footage showed <a href="http://thehill.com/homenews/senate/375835-rubios-approval-rating-near-all-time-low-in-florida-poll">Senator Marco Rubio</a> and the <a href="https://www.youtube.com/watch?v=4AtOU0dDXv8">NRA’s Dana Loesh</a> publicly sparring with students from Marjory Stoneman Douglas High, to a chorus of boos and jeers. Millions witnessed their discomfort.</p>
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<p>This has <a href="http://www.bbc.com/news/world-us-canada-43298384">already led to some action by states</a>. Florida is looking to pass age restrictions and waiting periods for gun purchases, and Oregon has imposed gun prohibitions on domestic abusers and those with restraining orders. </p>
<p>Even <a href="https://www.nytimes.com/2018/02/28/us/politics/trump-gun-control.html?hp&action=click&pgtype=Homepage&clickSource=story-heading&module=first-column-region&region=top-news&WT.nav=top-news">President Donald Trump</a>, who has <a href="http://www.bbc.com/news/av/world-us-canada-41479161/what-s-donald-trump-said-about-guns-and-gun-control">been keen to show off his pro-gun credentials in the past</a>, has recognised the public outcry. He has called for <a href="https://www.nytimes.com/2018/02/20/us/politics/trump-bump-stocks.html">regulation of bump-stocks</a> and <a href="https://edition.cnn.com/2018/02/27/politics/guns-donald-trump-sarah-sanders-age-limit/index.html">age restrictions</a> (though he is wavering on both).</p>
<h2>The high school advocates</h2>
<p>The reason gun control looks possible right now is largely due to <a href="https://www.nytimes.com/2018/02/25/us/florida-shooting-parkland-students.html">the students at Marjory Stoneman Douglas</a>. Beyond the pressure they have been applying directly to the NRA and politicians, the students have been busy using advocating on <a href="https://www.vox.com/2018/2/26/17054408/parkland-shooting-activist-teens-gun-control">social media</a>, writing <a href="https://www.nytimes.com/2018/02/26/opinion/florida-guns-training-trump.html">op-eds</a>, <a href="http://time.com/5169357/gun-control-rally-walkouts-us-capitol/">organising rallies and walkouts</a>, <a href="https://www.youtube.com/watch?v=47C-s0FMXlI">making media appearances</a>, <a href="https://www.theguardian.com/us-news/2018/feb/23/us-companies-nra-best-western-wyndham">and pressuring companies to drop support for the NRA or pro-gun politicians</a>.</p>
<p>As a result of these efforts, the students are presenting important, emotionally powerful counter-narratives to those of the gun lobby. They are <a href="http://www.abc.net.au/religion/articles/2018/02/23/4807913.htm">offering examples of successful gun control</a> and pointing out that guns in schools are the problem, not the solution. They are also forming a coalition in opposition to the well-organised <a href="https://www.washingtonpost.com/blogs/fact-checker/post/does-the-nra-really-have-more-than-45-million-members/2013/02/07/06047c10-7164-11e2-ac36-3d8d9dcaa2e2_blog.html?utm_term=.9c3ba8b65385">2-4 million members</a> of the NRA and affiliated organisations.</p>
<p>Whether these efforts are successful or not will depend largely on whether they are sustained. This is why the gun lobby calls for “hopes and prayers” and to not “politicise tragedy”. These are stalling tactics: if the NRA can wait it out, while at the same time applying pressure to its political allies, nothing gets done.</p>
<p>However, the gun lobby has not faced a political force like this before. While it is inevitable that media attention will eventually wane, the students from Marjory Stoneman Douglas and around the country have access to tools — such as social media — that circumvent traditional outlets. They also have the ability to draw the national spotlight back, especially via their use of rallies and walkouts.</p>
<p>These tactics reinvigorate the Democratic base and ratchet up the pressure on the Republicans, already jittery following a string of shock <a href="https://www.cnbc.com/2018/03/14/pa-election-results-paul-ryan-tries-to-calm-gop-after-conor-lamb-win.html">political losses</a>.</p>
<p>If the passion and dedication they have shown so far is sustained, especially as the <a href="https://www.nytimes.com/2018/02/27/us/politics/parkland-gun-control-politics-midterms.html">congressional midterm elections approach</a>, the young people of the US might just be able do what no one has done in decades, and force action on gun control.</p>
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<p><em>This article has been update to correct the statement that the federal assault weapons ban followed the Columbine school shooting.</em></p>
<hr><img src="https://counter.theconversation.com/content/92272/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>George Rennie does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Student activists are presenting important, emotionally powerful counter-narratives to those of the gun lobby. Their success will depend on whether they can sustain these efforts.George Rennie, Lecturer in American Politics and Lobbying Strategies, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/891142018-01-04T04:31:57Z2018-01-04T04:31:57ZFor richer or poorer: 4 economists ponder what 2018 has in store<figure><img src="https://images.theconversation.com/files/200762/original/file-20180103-26163-rc8vst.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">At least one economist worries we'll be mostly poorer. </span> <span class="attribution"><span class="source">AP Photo/Go Nakamura</span></span></figcaption></figure><p><em>Editor’s note: We asked four economists to offer their thoughts and insights on what they expect to be a key theme or issue in 2018.</em></p>
<h2>The Gilded Age returns</h2>
<p><strong>Greg Wright, assistant professor of economics, University of California, Merced</strong></p>
<p>Income and wealth inequality are currently at levels last seen during the Gilded Age – when the top 10 percent of Americans owned nearly three-fourths of overall wealth, and the bottom 40 percent had virtually no wealth – and 2018 will see things get a whole lot worse. </p>
<p>Now, the richest 1 percent of Americans <a href="https://www.washingtonpost.com/news/wonk/wp/2017/12/06/the-richest-1-percent-now-owns-more-of-the-countrys-wealth-than-at-any-time-in-the-past-50-years/?utm_term=.d5667081375e">own</a> 40 percent of U.S. wealth, more than the bottom 90 percent of Americans combined.</p>
<p>In spite of this, Congress just <a href="https://www.bloomberg.com/view/articles/2017-12-15/this-tax-bill-is-a-trillion-dollar-blunder?utm_medium=email&utm_source=newsletter&utm_term=171215&utm_campaign=sharetheview">significantly reduced taxes</a> on capital and on high-earning individuals. Other income earners got smaller, temporary cuts. </p>
<p>Meanwhile, the government <a href="http://www.cnn.com/2017/12/14/politics/chip-extended-states-funds-kimmel-authorization/index.html">has yet to renew</a> federal funding for the Children’s Health Insurance Program, a program affecting 9 million poor families, and the tax bill <a href="http://thehill.com/policy/healthcare/365185-final-gop-tax-bill-repeals-obamacare-mandate">repealed</a> the Affordable Care Act’s individual insurance mandate, which may ultimately lead to a loss of coverage for millions of low- and middle-income Americans. </p>
<p>Other policies that will be enacted or pursued in 2018 that could further widen the income gap include <a href="https://www.washingtonpost.com/news/wonk/wp/2017/12/01/gop-eyes-post-tax-cut-changes-to-welfare-medicare-and-social-security/?utm_term=.47b9ba4d34f5">cuts in important programs</a> like Social Security and Medicare and a continuing rollback of financial, environmental and other regulations that benefit a few companies at the expense of all Americans’ living standards. </p>
<p>Why does widening inequality matter? </p>
<p>While some argue that inequality is irrelevant as long as all incomes are rising, even that has not been true in the U.S. for decades. The average income for the bottom 50 percent of Americans <a href="https://www.theguardian.com/inequality/2017/dec/14/inequality-is-not-inevitable-but-the-us-experiment-is-a-recipe-for-divergence?CMP=share_btn_tw">has been unmoved</a> at US$16,000 since 1980. In addition, <a href="https://www.nytimes.com/2017/12/03/opinion/lost-einsteins-innovation-inequality.html?_r=1">recent evidence</a> indicates that family income in childhood is a strong predictor of the likelihood that an individual will produce innovations as an adult. Poverty and social inequality thus lead to “<a href="http://www.equality-of-opportunity.org/assets/documents/inventors_summary.pdf">lost Einsteins</a>.”</p>
<p>Not long after accepting the Nobel prize in economics in 2014, <a href="http://www.businessinsider.com/shiller-on-inequality-and-taxes-2014-4">Robert Schiller stated</a>, “If we wait until income inequality is much more severe, we will have a whole class of new superrich who will … feel entitled to their wealth and will have the means to defend their interest.” </p>
<p>In 2018 we may begin to put these fears to the test.</p>
<hr>
<h2>War on poverty, revisited</h2>
<p><strong>Patricia Smith, professor of economics, University of Michigan</strong></p>
<p>By many measures, such as <a href="http://www.oecdbetterlifeindex.org/topics/income/">GDP, income and wealth per household</a>, the U.S. is among the richest countries in the world.</p>
<p>At least one measure, however, makes the U.S. look not so rich: its poverty rate. The share of American households living on less than half of the national median income, a commonly used measure for international comparisons, is the <a href="http://www.oecd.org/social/society-at-a-glance-19991290.htm">second-highest in the developed world</a>, at 17.5 percent. While the <a href="https://www.census.gov/library/publications/2017/demo/p60-259.html">official U.S. poverty rate</a> puts that lower, at 12.7 percent, even by that measure <a href="https://www.ers.usda.gov/topics/rural-economy-population/rural-poverty-well-being/poverty-demographics.aspx#byage">over a quarter</a> of children under 5 lived in poverty in 2016. </p>
<p>Past presidents have tried several ways to fight poverty. Lyndon Johnson <a href="https://www.washingtonpost.com/news/wonk/wp/2014/01/08/everything-you-need-to-know-about-the-war-on-poverty/?utm_term=.0731c94acd9d">declared “unconditional war”</a> in 1964 and championed anti-poverty programs such as Medicare and Medicaid. Bill Clinton <a href="https://royce.house.gov/uploadedfiles/the%201996%20welfare%20reform%20law.pdf">changed the battle strategy</a> 32 years later by pushing people to work more. </p>
<p>House Speaker Paul Ryan has once again reopened the debate on how best to win the fight by <a href="https://www.cbsnews.com/videos/paul-ryan-talks-gop-tax-bill-denies-rumors-of-him-leaving-congress/">declaring</a> poverty will be a focus in 2018. The rhetoric of the <a href="https://abetterway.speaker.gov/?page=poverty">Republican plan</a> sounds promising, beginning with “If the American Dream isn’t true for everyone, it isn’t true for anyone.” It would make work more rewarding in anti-poverty programs and improve education and training. </p>
<p>But Ryan <a href="https://www.washingtonpost.com/news/wonk/wp/2017/12/01/gop-eyes-post-tax-cut-changes-to-welfare-medicare-and-social-security/?utm_term=.4753bd1e7f26">has also made clear</a> he plans to cut Medicaid, Medicare and other anti-poverty programs to reduce the national debt, all of which were central to reducing the official poverty rate from 22 percent in the early 1960s.</p>
<p>Part of the argument supporting a focus on cutting debt is that it <a href="http://www.heritage.org/budget-and-spending/report/cutting-the-us-budget-would-help-the-economy-grow">spurs growth</a>, which in turn reduces poverty. The U.S. did experience this prior to the mid-1970s, when growth <a href="http://www.epi.org/publication/raising-americas-pay/">appeared correlated with less poverty</a>. Since then, however, the poverty rate has responded little to economic growth.</p>
<p>In fact, the correlation may work the other way around because research suggests that lowering poverty rates cuts health care costs and federal spending and boosts growth. Specifically, improving health and nutrition for the poor <a href="http://blogs.reuters.com/nicholas-wapshott/2013/06/13/robert-fogel-and-the-economics-of-good-health/">is critical</a> to long-term growth, leading to <a href="http://science.sciencemag.org/content/287/5456/1207.full">higher productivity</a> and incomes. For example, economists estimate that the cost of childhood poverty in terms of <a href="https://confrontingpoverty.org/wp-content/uploads/2017/02/PAPER15.pdf">lost economic productivity approaches $294 billion</a> annually. </p>
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<h2>Economic optimism and health care</h2>
<p><strong>Christos Makridis, Ph.D. candidate in labor and public economics, Stanford University</strong></p>
<p>Americans began 2018 <a href="https://www.cnbc.com/2017/12/18/economic-optimism-soaring-helping-trump-cnbc-survey.html">more optimistic about the economy</a> than they’ve been in at least a decade.</p>
<p>How can the government sustain and build on this hopefulness – a <a href="http://stanford.edu/%7Ecmakridi/Makridis%20-%20Sentimental%20business%20cycles">key driver of consumer spending</a> – among individuals and <a href="https://www.colorado.edu/business/sites/default/files/attached-files/lbci_q1_2018.pdf">small businesses</a> in 2018? </p>
<p>In my view, one of the most important ways to do this is by reforming health care in a financially stable way. Rising health care costs and the tax plan’s <a href="http://fortune.com/2017/12/20/tax-bill-individual-mandate-obamacare/">repeal of the Affordable Care Act’s individual mandate</a> mean it’s urgent that Congress tackle this in 2018. Health care exchanges <a href="https://www.nytimes.com/2017/12/18/us/politics/tax-cut-obamacare-individual-mandate-repeal.html">may implode</a> without the mandate. </p>
<p>Health care spending made up a record <a href="https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html">18 percent of U.S. gross domestic product</a> in 2016, up from 17.3 percent five years earlier. While spending has slowed a bit from previous decades, it’s beginning to accelerate and is forecast to reach <a href="https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/proj2016.pdf">20 percent of the economy</a> by 2025. </p>
<p>Following last year’s tax cut, <a href="https://www.nytimes.com/2017/12/15/us/politics/republican-tax-bill.html">some in Congress</a> – perhaps ironically – are arguing that the focus now needs to be on reducing the budget deficit in the short term. But the deficit is a long-term problem that is nearly impossible to balance without figuring out a way to rein in health care spending in part because it makes up so much of the economy. </p>
<p>Scholars from <a href="https://bipartisanpolicy.org/library/future-of-health-care-bipartisan-policies-and-recommendations/">both sides</a> of the aisle agree the status quo is problematic: There is far <a href="https://www.brookings.edu/research/making-health-care-markets-work-competition-policy-for-health-care/">too little competition</a>, and <a href="https://hbr.org/2016/12/health-care-needs-real-competition">incentives are too weak</a>. While there is no easy answer, structural changes like <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3054172">introducing penalties</a> for poor hospital performance in Medicare reimbursement claims could help. </p>
<p>Health care is one of the few items that matters to literally everyone, from small business owners and corporate executives to households of all incomes. It’s also one of the trickiest because of its life and death nature, with quality of service difficult to gauge and costs often not borne directly by patients.</p>
<p>I believe the tax cut President Trump signed into law in December will help turn the current economic optimism into tangible reality for tens of millions of families. By tackling health care next, the government could continue that momentum. Delaying reform will only make things tougher down the road. </p>
<hr>
<h2>Trade takes center stage</h2>
<p><strong>William Hauk, associate professor of economics, University of South Carolina</strong></p>
<p>President Trump <a href="https://www.cbsnews.com/videos/trump-calls-nafta-a-disaster/">made it clear during the 2016 presidential campaign</a> that he intended to either renegotiate or withdraw from most of the United States’ international trade agreements. In 2018, he may finally focus his energy on these campaign promises, which would put our prosperity at risk.</p>
<p>Early on in 2017, he announced the U.S. withdrawal from the Trans-Pacific Partnership. We’re <a href="https://www.voanews.com/a/4100538.html">already</a> <a href="https://www.cnbc.com/2017/11/11/trans-pacific-trade-deal-advances-without-united-states.html">beginning</a> to see the negative impact of that decision. Our economic and political influence in Asia may decline in 2018 and the years ahead.</p>
<p>He has also set his sights on the North American Free Trade Agreement and began <a href="https://www.news.virginia.edu/content/nafta-20-primer-tense-negotiations-between-us-canada-and-mexico">renegotiating</a> its terms. Talks are likely to accelerate in 2018, with the pact’s unraveling a real possibility.</p>
<p>And in interviews, he has <a href="https://www.yahoo.com/news/trump-says-us-could-pull-world-trade-organization-154808319.html">declared the World Trade Organization</a> “a disaster.” </p>
<p>International trade deals are an often misunderstood part of U.S. economic policy. However, they can have a large impact on the economy.</p>
<p>Since the end of World War II, the U.S. has taken the lead in setting up a multilateral, rules-based system of international trade. <a href="https://www.wto.org/english/thewto_e/whatis_e/tif_e/fact4_e.htm">Central to this system</a> was the General Agreement on Tariffs and Trade. In 1994, this agreement was transformed into the WTO.</p>
<p>Under this system, world trade has expanded dramatically over the last 70 years. In 1947, <a href="http://www.hamiltonproject.org/charts/u.s._imports_and_exports_1947_2016">trade accounted for</a> approximately 6 percent of U.S. gross domestic product, whereas it now accounts for approximately 15 percent. Today, U.S. exports <a href="https://ustr.gov/about-us/benefits-trade">support over 11 million jobs</a>, while imports of many staples from overseas <a href="http://americastradepolicy.com/aafa-imports-benefit-the-u-s-worker-and-consumer/#.WkIw8VWnEqM">increase the purchasing power of domestic households</a>.</p>
<p>A retreat from a multilateral rules-based system of trade brings with it many problems. Domestically, it increases the probability of “trade wars” with our major trading partners. Relatively minor disputes could easily escalate into trade sanctions and counter-sanctions, like in the <a href="http://money.cnn.com/2016/07/07/news/economy/trump-trade-smoot-hawley/index.html">aftermath of the Depression-era Smoot-Hawley Tariff</a>, which raised tariffs on hundreds of imports.</p>
<p>Internationally, it could make it more difficult for developing countries to engage in trade relations with their much larger and wealthier counterparts.</p>
<p>While the Trump administration has drawn attention to the U.S.’s large trade deficit, most economists agree that <a href="https://piie.com/blogs/trade-investment-policy-watch/free-trade-agreements-and-trade-deficits">trade agreements have little to no effect on that</a>. </p>
<p>Certainly, some aspects of institutions such as NAFTA and the WTO can be questioned. However, a general retreat from the postwar system of trade could be a dangerous path for both the U.S. and the broader world economy.</p><img src="https://counter.theconversation.com/content/89114/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christos Makridis has received funding from the National Science Foundation. </span></em></p><p class="fine-print"><em><span>William Hauk has received funding from the Center for International Business Education and Research. </span></em></p><p class="fine-print"><em><span>Greg Wright and Patricia Smith do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>We asked four of our regular economics writers to examine a key theme they expect to flare up in 2018 and why.Greg Wright, Assistant Professor of Economics, University of California, MercedChristos A. Makridis, Ph.D. Candidate in Labor and Public Economics, Stanford UniversityPatricia Smith, Professor of Economics, University of MichiganWilliam Hauk, Associate Professor of Economics, University of South CarolinaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/818002017-08-04T01:58:33Z2017-08-04T01:58:33ZWhat does choice mean when it comes to health care?<figure><img src="https://images.theconversation.com/files/180948/original/file-20170803-29097-xc6w41.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">For many, the heart of the health care debate is the ability of patients to choose their own health care, including whether to buy insurance and which doctor to see. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-patient-665808985?src=Pdsi6uHSlIvHgSRUUk28lA-2-79">Alpa Prod/Shutterstock.com</a></span></figcaption></figure><p>President Trump <a href="http://www.newyorker.com/news/john-cassidy/trumps-health-care-threats-are-nothing-but-spite-and-fury">continues to threaten</a> millions of Americans who now have health insurance with loss of coverage by <a href="https://theconversation.com/trump-isnt-letting-obamacare-die-hes-trying-to-kill-it-81373">undermining the Affordable Care Act</a>, commonly known as “Obamacare.” His goal has been to repeal the ACA, or to have it repealed by a version of congressional bills. </p>
<p>A <a href="https://www.washingtonpost.com/powerpost/the-night-john-mccain-killed-the-gops-health-care-fight/2017/07/28/f5acce58-7361-11e7-8f39-eeb7d3a2d304_story.html?utm_term=.974c84f7b967">July 28 vote killed the Senate bill</a> temporarily, but the threat to those with coverage through the ACA is not over.</p>
<p>As we await the next proposals and rounds of debates, now is a good time to reflect on what the <a href="https://www.forbes.com/sites/theapothecary/2017/01/20/obamacares-individual-mandate-is-really-inefficient/#5ef651ef3ecb">Republicans most detested about Obamacare</a> – the individual mandate, which they argued took away personal choice. The mandate was an essential part of the law, however, by guaranteeing insurers that they would have a large enough pool of healthy people to offset the costs of insuring large numbers of unhealthy people.</p>
<p>As a philosopher of health policy, I think it could be instructional to assess their recent proposals through their lens of “choice.” </p>
<h2>Universal access and choice</h2>
<p>The public debate on proposed health care laws has focused largely on the number of uninsured, which would be lower if we moved to universal coverage. Many experts, advocates and nonprofit research groups, such as Kaiser Family Foundation, use the proportion of people who are covered as a quick way to test whether people have real access to health care. We got partway there with the ACA, with the percentage of <a href="http://www.kff.org/other/state-indicator/total-population/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">uninsured dropping to 9 percent</a> in 2015. </p>
<p>After Trump was elected, Republicans tried to come up with bills, however, that focused not on reducing the number of uninsured but on ensuring that people had a choice about whether to buy insurance. They fought the mandate from the law’s beginnings, filing a lawsuit that reached the U.S. Supreme Court. Chief Justice John Roberts, a George W. Bush appointee, wrote the <a href="http://www.nytimes.com/2012/06/29/us/supreme-court-lets-health-law-largely-stand.html">majority opinion that the mandate did not violate</a> the commerce clause of the Constitution.</p>
<p>If we take them at their word, the system the Republicans aim to replace the ACA with should be focused more on the choices people have, not the number of people who gain insurance. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/180944/original/file-20170803-4947-fxl5km.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/180944/original/file-20170803-4947-fxl5km.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=470&fit=crop&dpr=1 600w, https://images.theconversation.com/files/180944/original/file-20170803-4947-fxl5km.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=470&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/180944/original/file-20170803-4947-fxl5km.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=470&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/180944/original/file-20170803-4947-fxl5km.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=590&fit=crop&dpr=1 754w, https://images.theconversation.com/files/180944/original/file-20170803-4947-fxl5km.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=590&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/180944/original/file-20170803-4947-fxl5km.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=590&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">President Trump and House Speaker Paul Ryan celebrated at the White House on May 5, when the House of Representatives passed Ryan’s version of a health care bill.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Trump-Health-Care-Key-Moments/826c4035d73941b294a6089984bb81a9/1/0">AP Photo/Evan Vucci</a></span>
</figcaption>
</figure>
<p>The public should take seriously, at least for the sake of argument, the words of<a href="http://www.newsweek.com/resistance-resists-too-often-paul-ryan-health-care-trump-trumpcare-629479"> Paul Ryan</a>, when he said that no one should have to do something they do not want to do. <a href="https://www.usatoday.com/story/opinion/2017/03/13/paul-ryan-cbo-health-care-editorials-debates/99143928/">“Our plan is not about forcing people to buy expensive, one-size-fits-all coverage</a>. It is about giving people more choices and better access to a plan they want and can afford,” Ryan said in a statement issued in March 2017. </p>
<p>Their intent is to replace the goal of universal coverage with an alternative which some have called <a href="https://www.nytimes.com/2016/12/15/us/politics/paul-ryan-affordable-care-act-repeal.html?_r=0">“universal access.”</a> Universal access aims to give people the “choice” of having coverage or foregoing that coverage for other priorities they may have.</p>
<h2>What would a real choice require?</h2>
<p>To have a real choice, people would have to be able to buy insurance plans that meet their possible health needs, both for prevention and treatment. They could compare that choice with the choice to forego coverage. </p>
<p>This means they are not in the position of having only a forced choice. If they have a real choice, they no longer are choosing between a plan they can afford, whose reduced cost reflects the fact that it fails to provide access to preventive or treatment services they want and need, and one they cannot afford at all, though it provides access to the preventive and treatment needs they come to have. </p>
<p>Millions in the U.S. faced such a forced “choice” when they bought in the individual health insurance that preceded the ACA marketplaces.</p>
<p>Such a choice is not a real choice. It is forced because the outcome is determined by limited resources and the lack of freedom that the situation creates.</p>
<h2>Paying for real choice</h2>
<p>Of course, since some goods we want, like cars, come in different brands with different prices, we may not see buying a Chevy instead of a Mercedes as a loss of freedom. If we only want a way to get from A to B, we might not care that the Mercedes provides a better ride and is more prestigious.</p>
<p>But, in buying access to health care, we all want the best care. We all, correctly, think that we are valuable in the ways that health care systems should respect even if we have other preferences and priorities regarding cars. In short, people generally accept ability to pay as a principle for car purchases, but not as a principle for buying access to needed health care.</p>
<p>Accordingly, the Republican effort to avoid coercion and take choice seriously would cost more than their plans allow. </p>
<p>The plans they have offered significantly reduce subsidies to the poor and throw people out of Medicaid, resulting in an <a href="http://healthaffairs.org/blog/2017/06/26/cbo-projects-that-22-million-would-lose-coverage-under-senate-bill/">estimated 22 million people losing insurance</a> coverage. The result is a forced choice, not a real choice, especially for people who want some coverage and perhaps need it but have limited resources that would have qualified them for Medicare or subsidies.</p>
<h2>What happens when some people ‘choose’ to forego coverage?</h2>
<p>The Republican approach does not seem to take into account that even a real choice to forego coverage imposes harms on third parties. It does so by raising the cost and thus limiting the availability of insurance to other people. </p>
<p>Since the Republican plans purport to care about the choices for everyone, these consequences – the harms they impose – are ethical reasons to oppose them on their own terms. Young, healthy people should not be able to “choose” to forego coverage when older, sicker people face only forced choices.</p>
<p>Many people want coverage. What happens to the costs of insurance if the system allows people, who save money by foregoing coverage while they are young and healthier than the average older, sicker person, to receive needed emergency care when they need it? </p>
<p>Consider “free riders,” who may be anyone who foregoes buying insurance coverage but later can get needed health care. The cost of a system that allows people to join it when they have not shared in the cost of providing that care is greater than the cost of a system that excludes such “free riders.” </p>
<p>So allowing those who free ride not to die in the streets when they need care, which is what the existing system of emergency medical care (EMTALA) intends and which Republican plans do not challenge, means that free riding imposes higher costs on those who buy insurance coverage. This is a harm to those who have a real choice to buy coverage. This harm to others involves a cost that goes beyond the unfairness of allowing those who do not contribute their fair share to enjoy the benefit of health care when they need it.</p>
<p>Creating this incentive to free ride is part of what creating “choice” – as envisioned by Republicans – involves. </p>
<h2>Skimpy plans</h2>
<p>Similarly, the <a href="http://thehill.com/policy/healthcare/340570-cruz-plan-could-be-key-to-unlocking-healthcare-votes">Cruz amendment</a>, proposed by Sen. Ted Cruz (R-Texas), to the recent Senate bill would have allowed insurers to market less expensive plans that skimp on needed health care as long as the insurer also markets less skimpy plans at higher prices.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/180945/original/file-20170803-17289-ofxbpa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/180945/original/file-20170803-17289-ofxbpa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/180945/original/file-20170803-17289-ofxbpa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/180945/original/file-20170803-17289-ofxbpa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/180945/original/file-20170803-17289-ofxbpa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/180945/original/file-20170803-17289-ofxbpa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/180945/original/file-20170803-17289-ofxbpa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Sen. Ted Cruz (R-Texas).</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/sioux-center-iowa-january-5-2016-358800029?src=GaOBgP2LzPVylfb9248ecg-1-0">Rich Koele/Shutterstock.com</a></span>
</figcaption>
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<p>But the increasing stratification that this amendment produces means greater costs to those who buy less skimpy insurance, harming them. (At the same time, those people facing a forced choice of the skimpy insurance or less skimpy but unaffordable insurance are said to simply “choose” it.)</p>
<p>In sum, the “choice” underlying the congressional plans not only is not really paid for, but exercising that “choice” would harm others in a way that undercuts any appeal it has. Universal access is worse than universal coverage because of the “choice” it creates. </p>
<p><em>Brendan Saloner, assistant professor at the Bloomberg School of Public Health at Johns Hopkins University and a former student of Prof. Daniels, contributed to research for this article.</em></p><img src="https://counter.theconversation.com/content/81800/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Norman Daniels does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The Republican position on health care has been based upon a belief in individual choice. Here’s how their own versions of health care bills eroded choice, however, and how they also did harm.Norman Daniels, Professor of Population Ethics and Professor of Ethics and Population Health, Harvard UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/813772017-07-24T02:26:16Z2017-07-24T02:26:16ZMitch McConnell, the president’s man in the Senate<p>Being Senate majority leader isn’t easy. And Mitch McConnell is finding out that having unified government could make it harder still. </p>
<p>As my research shows, <a href="http://www.cambriapress.com/cambriapress.cfm?template=4&bid=387">U.S. Senate majority leaders represent several constituencies</a> that push and pull in multiple – and usually conflicting – directions. </p>
<h2>Balancing constraints</h2>
<p>First, the leader is a senator responsible for representing the interests of his state – in McConnell’s case, Kentucky. </p>
<p>Second, like all majority leaders, McConnell is the leader of his party in the Senate, with an obligation to get more Republicans elected to office and to push a legislative agenda that burnishes the party label.</p>
<p>Third, as leader of the Senate, his duty is to sustain the institutional health of that chamber in its function as a counterweight to the whims of the House of Representatives, the ambitions of the executive branch and even the rulings of the judiciary. </p>
<p>Balancing the demands of the office’s various constituencies is sometimes further complicated by another demand on the Senate majority leader – the president, who in times of unified government becomes a fourth constituency to which the leader must answer. </p>
<p>Of course, that’s the position McConnell finds himself in with Donald Trump.</p>
<p>To understand why McConnell must answer to the president, it helps to know some history.</p>
<h2>It started with Wilson</h2>
<p>Unlike the speaker of the House, the U.S. Senate majority leader is not a constitutional office. Its functions were originally assumed to be the purview of the president of the Senate, a role played by the vice president, or in his absence, a senator acting as the <a href="https://www.senate.gov/reference/Index/President_Pro_Tempore.htm">president pro tempore</a>. </p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/179286/original/file-20170722-28519-1fch3ev.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/179286/original/file-20170722-28519-1fch3ev.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/179286/original/file-20170722-28519-1fch3ev.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/179286/original/file-20170722-28519-1fch3ev.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/179286/original/file-20170722-28519-1fch3ev.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/179286/original/file-20170722-28519-1fch3ev.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1006&fit=crop&dpr=1 754w, https://images.theconversation.com/files/179286/original/file-20170722-28519-1fch3ev.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1006&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/179286/original/file-20170722-28519-1fch3ev.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1006&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">John W. Kern.</span>
<span class="attribution"><a class="source" href="http://www.loc.gov/pictures/collection/hec/item/hec2009003594/">Harris & Ewing/Library of Congress</a></span>
</figcaption>
</figure>
<p>That <a href="https://www.senate.gov/reference/reference_item/first_among_equals.htm">arrangement proved unsatisfactory</a> to President Woodrow Wilson. Before entering politics, Wilson was an academic – a political scientist whose research advocated for parliamentary government. He became a president interested in legislating. Separation of powers meant that Wilson needed an advocate in the Senate to advance his plans for a “New Freedom,” as he called his program of progressive reforms. Senator John W. Kern, a Democrat from Indiana, became his willing partner, having proven himself a stalwart on progressive policy in his first two years in the Senate. In 1913, Kern – with the support of Wilson and progressives in the Democratic Party – won a contested leadership election in the Senate and was the first senator to be called “majority leader.”</p>
<p>The relationship between president and Senate majority leader was so close that in the secrecy of night Kern would walk from the Capitol to the White House to meet with Wilson to discuss legislative strategy. As majority leader, Kern became Wilson’s man in the Senate, managing the president’s agenda in committee and on the floor. He set a precedent that has continued for his successors – particularly when the same party controls the Senate and the White House.</p>
<h2>Crazy like a fox</h2>
<p>From this perspective, McConnell’s actions on health care are an entirely predictable strategy to meet the demands of his party and his president. </p>
<p>To repeal and replace the Affordable Care Act (“Obamacare”) has been the goal of congressional Republicans since <a href="https://prescriptions.blogs.nytimes.com/2010/01/14/a-pledge-to-repeal-health-care-legislation/">before the law was passed</a>. Among rank-and-file members of the GOP, it was a key factor in energizing a grassroots movement – the <a href="https://global.oup.com/academic/product/the-tea-party-and-the-remaking-of-republican-conservatism-9780190633660?cc=us&lang=en&">Tea Party</a> – that delivered divided government for the final six years of the Obama administration. In that time, the Republican-led House voted <a href="http://www.reuters.com/article/us-usa-obamacare-idUSKBN14X1SK">more than 60 times to overturn the law</a>. It’s no surprise, then, that Donald Trump found opposition to Obamacare fodder on the 2016 campaign trail and <a href="https://thinkprogress.org/trump-promised-to-repeal-obamacare-many-times-ab9500dad31e">adopted Republican calls to repeal</a> and replace the program.</p>
<p>Unlike Wilson, however, Trump shows no appetite for the minutia of crafting policy or the legislative process. Rather than leading with a specific health policy of his own, the president left it to his congressional Republicans to fulfill his promise to repeal and replace Obamacare. </p>
<p>Speaker Paul Ryan used his solid, but not overwhelming, majority <a href="https://www.nytimes.com/2017/05/04/us/politics/health-care-bill-vote.html?_r=0">to deliver a House bill</a>. The burden then fell on McConnell to deliver for the Senate. A bill <a href="https://www.nytimes.com/2017/05/08/us/politics/women-health-care-senate.html?_r=0">designed by 13 male senators working in secret</a> failed to pass even the motion to proceed – twice. Apparently, without a substitute plan, McConnell then proposed a vote on repeal only, reserving a replacement for a future Congress. On this, too, his party is fractured. Three senators – Shelley Moore Capito of West Virginia, Susan Collins of Maine and Lisa Murkowski of Alaska – have said they won’t support the bill. That’s enough to keep it from even being debated. </p>
<h2>Why call the vote?</h2>
<p>But McConnell is not caving to the numbers. He <a href="https://www.reuters.com/article/us-usa-healthcare-idUSKBN1A80QG">intends to call</a> a vote on a version of the healthcare legislation anyway. </p>
<p>Why? McConnell is attempting to balance the multiple constituencies of his office. </p>
<p>Trump has pledged to repeal and replace Obamacare. Despite – or perhaps because of – his hands-off approach to policymaking, he expects his Senate majority leader to work the legislative process to fulfill that promise. In calling for a vote – even one presumably destined to fail – McConnell serves as the president’s dutiful lieutenant, following orders even with no anticipation of victory. </p>
<p>He’s serving his party’s interests as well. Except for the few defectors among Republicans in the Senate, the party remains unified in its aim to roll back the signature piece of legislation from the Obama presidency. “Repeal and replace” has been the mantra of the past four elections that ushered many of the current members of Congress into office. The point of calling a failed vote is to establish a record of performance for those Republicans who vote for the repeal and especially for those who do not. </p>
<p>Political scientist <a href="https://books.google.com/books/about/Congress.html?id=j17QomTrD1EC">David Mayhew described position-taking</a> by members of Congress in which voting forces them to go on record and commit to an issue position. Often this strategy is used against the opposing party. Here, McConnell’s insistence on a vote to repeal Obamacare is a coercive tactic against members of his own party. It can be viewed only, I would argue, as a precursor to a purge, an attempt to identify those Republicans who, despite years of riding the repeal bandwagon, ultimately can’t bring themselves to abolish an established and popular entitlement program. The vote stands to be an ideological purifier that likely strengthens those who vote for repeal and ensures a primary challenge for those who do not. </p>
<p>But McConnell no doubt has his first constituency – the state of Kentucky – in mind as well. I’ve examined those rare instances when <a href="https://doi.org/10.2202/1540-8884.1452">Senate majority leaders lose their seats</a>. Here again the origins of the office are significant to the way it works today. That is, a majority leader’s electability is strongly tied to his relationship with the president. </p>
<p>Consider the examples of Tom Daschle and Harry Reid. As Senate majority leader from 2001 to 2003 and thus the highest-ranking Democrat, Daschle was forced to lead the opposition against President George W. Bush, who won Daschle’s home state of South Dakota with <a href="http://www.nytimes.com/ref/elections2004/2004SD.html">60 percent of the vote</a>. </p>
<p>On the flip side, Harry Reid found himself in a tough race in 2010. But as Senate majority leader, he had the advantage of serving a Democratic president who was popular in his state. Barack Obama won Nevada by a 12.5 percent margin over Republican John McCain in 2008. Being the president’s man wasn’t the only reason Reid won, but it was a factor in his victory against a Tea Party wave. </p>
<p><a href="https://www.nytimes.com/elections/results/kentucky">Donald Trump won Kentucky</a> in 2016 with 62.5 percent of the vote, a margin of nearly 30 percent over Hillary Clinton and an increase of 8 percent over the Democratic nominee from 2012. As long as Trump remains popular in Kentucky and among Republicans, McConnell will find it possible to balance his multiple constituencies by being the president’s man in the Senate.</p><img src="https://counter.theconversation.com/content/81377/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrea Hatcher does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Why would McConnell push a vote to repeal Obamacare when he knows it won’t pass? It’s not as crazy as it sounds.Andrea Hatcher, Associate Professor and Chair of Department of Politics, Sewanee: The University of the SouthLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/803082017-07-19T06:40:40Z2017-07-19T06:40:40ZRepublicans fail on health care. Here’s why the rest of Trump’s agenda won’t be ‘so easy,’ either<figure><img src="https://images.theconversation.com/files/178724/original/file-20170718-24356-pnpncr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Sen. Rand Paul speaks at a news conference on Capitol Hill.</span> <span class="attribution"><span class="source">AP Photo/Andrew Harnik</span></span></figcaption></figure><p>Passing legislation is always a difficult, messy task. America’s highly polarized political environment, with party activists demanding ideological purity on both sides of the aisle, makes that task even harder.</p>
<p>The announcement by Senators Mike Lee and Jerry Moran that they would oppose bringing the Better Care Reconciliation Act to the Senate floor has <a href="https://www.nytimes.com/2017/07/17/us/politics/health-care-overhaul-collapses-as-two-republican-senators-defect.html?_r=0">derailed Republican attempts</a> to replace the Affordable Care Act. </p>
<p>During his campaign, <a href="https://www.realclearpolitics.com/video/2016/10/25/trump_repealing_obamacare_is_going_to_be_so_easy.html">Donald Trump claimed</a> that passing health care reform would be “so easy.” So why were Republicans unable to pass a health care law despite controlling both the White House and Congress?</p>
<p>It turns out that the relationship between Congress and the president is more complicated than Trump thought. Most citizens and <a href="https://www.amazon.com/Ideology-Congress-Keith-T-Poole/dp/1412806089">political scientists</a> assumed that conservative Republicans <a href="http://press.uchicago.edu/ucp/books/book/chicago/P/bo3616471.html">would prefer any health care law</a> that Trump supported over the Obamacare status quo.</p>
<p>However, my <a href="http://www.tandfonline.com/doi/abs/10.1080/07343469.2015.1122671">research</a> shows that this assumption is too simplistic. As Trump now knows, ideological extremists may also vote against bills proposed by their party’s president. The recent struggle to pass a Republican health care law is a prominent example of this phenomenon.</p>
<h2>Trump’s two-sided task</h2>
<p>President Trump, House Speaker Paul Ryan and Senate Majority Leader Mitch McConnell are waging a legislative battle on two fronts with no compromise in sight. Both moderate Republicans and extremely conservative Republicans oppose the current health care bill for <a href="https://www.nytimes.com/interactive/2017/07/13/us/senate-health-care-bill-changes.html">completely separate reasons</a>.</p>
<p>Moderate Republicans are concerned about how Medicaid cuts and changes to Obamacare regulations, like guaranteed essential health benefits and protections for people with preexisting conditions, will affect their constituents. On the other hand, extremely conservative Republicans want to both remove those Obamacare regulations and repeal all Obamacare taxes. This puts Republicans leaders in a bind. Anything they do to please moderates will tend to alienate the extreme conservatives, and vice versa.</p>
<p>The House passed the American Health Care Act thanks to support from extremely conservative members who switched their votes to <a href="https://www.nytimes.com/2017/04/26/us/politics/affordable-care-act-health-republicans.html">support the bill</a>. This may explain why Majority Leader McConnell’s strategy seemed more focused on winning conservative support than moderate support. The major change to the most recent version of the health care bill was the Cruz Amendment, which would allow insurance companies to offer low-cost plans that provide coverage that is much less than the <a href="http://thehill.com/policy/healthcare/341828-new-gop-healthcare-bill-includes-version-of-cruz-amendment">standards set by Obamacare</a>. Yet this bill did not provide <a href="http://www.nbcnews.com/politics/congress/major-health-care-changes-senate-gop-bill-n782691">funding for Planned Parenthood or protect Medicaid</a>, two provisions that a number of moderate Republicans like Susan Collins, Shelley Moore Capito, Rob Portman and Lisa Murkowski wanted to see included.</p>
<p>The president’s strategy seemed to focus on conservatives as well. The list of senators invited to the White House on July 17 to solidify support for the bill included a number of conservative senators and <a href="http://www.politico.com/story/2017/07/17/trump-obamacare-repeal-senators-outreach-240636">almost no moderates</a>. </p>
<h2>Moving down the agenda</h2>
<p>After the original bill’s failure, both Trump and McConnell wanted the Senate to vote on a bill to completely repeal the Affordable Care Act <a href="http://abcnews.go.com/Politics/mcconnell-calls-obamacare-repeal-vote-replacement-plan-fails/story?id=48690900">after a two-year delay</a>. This gambit was essentially Republican leadership playing chicken in two ways.</p>
<p>First, leadership dared rank-and-file Republicans to vote against a repeal bill because most Republicans campaigned on the premise that the ACA should be repealed. However, doing so could potentially create chaos in the health care market.</p>
<p>Second, if Congress failed to pass a replacement health care bill within the next two years, chaos would ensue. Congress often gives itself such incentives in order to <a href="https://www.polisci.washington.edu/research/publications/congress-and-politics-problem-solving">promote compromise</a>. The major problem with this tactic is that Republican leadership would still have to find a way to placate both moderates and extreme conservatives, and potentially Democrats as well. While legislative compromise used to be a regular occurrence, it is becoming rarer in recent times due to increased polarization. Legislative productivity is near an <a href="https://www.washingtonpost.com/news/the-fix/wp/2014/04/10/president-obama-said-the-113th-congress-is-the-least-productive-ever-is-he-right/?utm_term=.11d0739d6811">all-time low</a>.</p>
<p>The August 2011 budget deal is the last major example of Congress creating a potentially negative situation in order to incentivize cooperation. The bill created the “sequester,” which threatened to cut government spending across the board beginning in 2013 if Congress was unable to come to <a href="http://money.cnn.com/2011/08/01/news/economy/debt_ceiling_breakdown_of_deal/index.htm">an agreement by that date</a>. The idea was that neither Democrats nor Republicans wanted that to happen, so they would be forced to make a deal. While the sequester was intended to bridge differences between the two parties, a repeal and delay plan would be intended to bring Republican moderates and extreme conservatives to the bargaining table.</p>
<p>The trouble is that the sequester gambit failed miserably. While Congress made some small deals on both military and social spending, the 2011 sequestration agreement is still largely in effect. It <a href="https://www.theatlantic.com/politics/archive/2017/03/donald-trump-meet-sequestration/519798/">looms over budget policy today</a>. Democrats and Republicans still refuse to compromise on most budgetary issues. Republicans run the risk of the same thing occurring with health care policy if they decide to fully repeal the Affordable Care Act without a replacement in place.</p>
<p>In order to repeal and replace Obamacare, Republicans needed to strike a deal that pleased both moderates and conservatives. It seems unlikely that such a deal exists. </p>
<p>The big question moving forward is whether such a deal is possible on taxes, infrastructure, the border wall and other major parts of President Trump’s legislative agenda. In my opinion, tax reform is the item that is most likely to become law. But Republicans’ failure on health care could foreshadow an inability to bridge the moderate-conservative divide on other major issues as well.</p><img src="https://counter.theconversation.com/content/80308/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Patrick T. Hickey does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>It turns out a unified government isn’t enough to get bills passed.Patrick T. Hickey, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/809432017-07-13T00:02:11Z2017-07-13T00:02:11ZThe 5 faulty beliefs that have led to Republican dysfunction on health care<figure><img src="https://images.theconversation.com/files/177961/original/file-20170712-13319-sfkcc2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Senate Majority Leader Mitch McConnell, shown here in June, 2017, is the architect of the new version of the Senate health care bill released today. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Congress-Health-Overhaul-Analysis/715f0700728a4a83b98fceb853661af7/23/0">AP Photo/J. Scott Applewhite</a></span></figcaption></figure><p>After failure of Republicans to reform health care, an outside observer might think that Congress is just dysfunctional, lurching from one extreme to another in search of something that works for health care reform. </p>
<p>The latest development has been the inability of Republicans to even agree on their own proposal and, worse yet, what should come next if it fails. Should they repeal the Affordable Care Act and worry about a replacement later or just try to “fix” the ACA now?</p>
<p>But the problem is much deeper than just a policy fix. As a former health insurance CEO and professor of health finance, it seems clear to me that Republicans are making five key implicit assumptions that are inherently problematic:</p>
<h2>1. If it’s your own money, you’ll be more careful in how you’ll spend it.</h2>
<p>This foundational belief rests on general experience in markets for most goods, and it has led to Republican support for Health Savings Accounts (HSAs), in which people set aside their own money to pay for their health care costs. </p>
<p>Landmark research showed that this approach could work – but under special conditions. The <a href="https://www.rand.org/health/projects/hie.html">RAND Health Insurance Experiment</a> is the basis for current HSAs. It demonstrated that people could save money – with no worsening of their health – if the cost sharing (deductibles and co-pays) was completely prefunded in individual HSAs. The only major exceptions were for kids and some chronic conditions. </p>
<p>But current proposals have extended this logic to populations, such as those with low incomes and few assets, where these findings are not applicable. Furthermore, HSAs generally are not fully funded to the levels used in the RAND research.</p>
<p>Yet, the Better Care Reconciliation Act, as the current Senate bill is officially called, adds a substantial boost to HSAs, and most state-level Medicaid proposals include a modestly funded health savings account. The problem with this Republican approach is that poor people don’t have any money to begin with and typically can’t afford to buy insurance or pay deductibles. </p>
<p>Furthermore, even those with more money aren’t very good at using their HSA money to shop for care, due to opaque prices for services and lack of information about treatment requirements. </p>
<h2>2. Many or most poor people (Medicaid recipients) can work and should contribute to pay for insurance.</h2>
<p>While the Medicaid expansion enrollees are working already (by definition, they have income above the poverty line), their <a href="http://ccf.georgetown.edu/wp-content/uploads/2013/09/GW-Continuity-Report-9-10-13.pdf">job prospects and history are marginal</a>. The 30,000 Medicaid recipients in the health insurance plan that I ran as CEO, for example, had about nine months of Medicaid eligibility before they got a job and lost coverage. </p>
<p>But the myth persists that Medicaid is loaded with moochers who simply do not choose to work and won’t pay for coverage anyway. </p>
<p>The fact is that very few fall in this category. <a href="http://healthaffairs.org/blog/2017/06/07/state-medicaid-lessons-for-federal-health-reform/">Work requirements and required premiums</a> may be simply a way to reduce Medicaid rolls using a faulty assumption. </p>
<h2>3. Government restrictions are holding back insurers from competition that would drive costs lower.</h2>
<p>Both the Senate and House alternatives cut restrictions and taxes on insurers. Most important of these are the broadening of the range of premiums allowed and the elimination or weakening of required <a href="https://theconversation.com/essential-health-benefits-suddenly-at-center-of-health-care-debate-but-what-are-they-75125">essential health benefits</a>, such as preventive care and maternity coverage. Undoubtedly, these changes will allow premiums to drop – but primarily for the healthy population that needs insurance less while others pay more.</p>
<p><a href="http://www.commonwealthfund.org/publications/blog/2017/apr/selling-health-insurance-across-state-lines">Cross-state competition</a> among insurers is a big Republican talking point. The rules of Congress exclude consideration for this particular legislation, however.</p>
<p>What’s more, it is wishful thinking that, with less regulation, there would be a flood of out-of-state insurers entering new markets and driving health care costs down. Insurers are able to compete on premiums by obtaining favorable contracts with providers. New entrants simply won’t get rates comparable to those already in a market.</p>
<p>In any event, the fact is that it is recent government-induced uncertainty that is <a href="http://www.modernhealthcare.com/article/20170510/NEWS/170519999">driving insurers out of the market</a> and forcing huge increases in premiums filed for 2018 offerings. </p>
<p>It is more than ironic that Senate Majority Leader Mitch McConnell suggested that they may need to “<a href="http://khn.org/morning-breakout/mcconnell-concedes-bill-might-not-pass-but-reaffirms-need-to-shore-up-individual-markets/">shore up the individual market</a>” when the Congress has been the main reason for the instability.</p>
<h2>4. Physicians should be the only ones making care decisions (with the consent of their patients) since they know best.</h2>
<p>Health and Human Services Secretary Tom Price, an orthopedic surgeon, was a vocal advocate of this view – before he accepted the Cabinet job.</p>
<p>Recently, however, from my observations, he seems to have discovered that payment incentives and organizational innovation actually do improve quality, satisfaction and cost. </p>
<p>Perhaps acknowledging this, the Senate plan sought to extend these payment incentives and other ACA innovations through a new “Medicaid Flexibility Program” under its <a href="http://healthaffairs.org/blog/2017/06/24/medicaid-round-two-the-senates-draft-better-care-reconciliation-act-of-2017/">block grant options</a> to the states. </p>
<p>Unfortunately, however, the total amount of <a href="https://www.nytimes.com/interactive/2017/06/26/us/cbo-score-of-senate-health-care-bill.html">funds available to state Medicaid programs</a> would have been cut dramatically. On the principle, however, the Republicans seem to have conceded that health care is a team sport requiring action regarding incentives, organization and knowledge, much like the Democrats, albeit with less funding.</p>
<h2>5. Government should help people – but not too much.</h2>
<p>The original flat premium subsidies proposed by the House are both inadequate and regressive – hurting those with lower incomes. They would have covered almost all of the premium for young people but perhaps half for older enrollees. Also, they would go to everyone regardless of income, unlike Obamacare subsidies, which were based on a defined percent of the purchaser’s income. </p>
<p>The Senate partially corrects this bad arithmetic – and economics – by allowing subsidies to vary somewhat by income. Unfortunately, the base level is far lower than under the ACA. Subsidies are cut substantially for the poor while giving the wealthy tax relief.</p>
<h2>What next?</h2>
<p>So the bottom line is that the <a href="https://www.nytimes.com/2017/07/18/us/politics/republicans-obamacare-repeal-now-replace-later.html?emc=edit_th_20170719&nl=todaysheadlines&nlid=47546052">implosion of the Obamacare exchanges</a> that Republicans have predicted may become a self-fulfilling prophecy under continued threats to sabotage it by administrative action or inaction.</p>
<p>Unfortunately, even with the demise of the Senate bill, it is likely that the grand experiment of Obamacare – advancing the social objective of a fully insured population using a competitive but regulated marketplace – will fade away as insurers run away from <a href="https://www.nytimes.com/2017/01/17/opinion/the-gops-health-care-death-spiral.html">unpredictable markets</a>. </p>
<p>We may come full circle. We could end up with a dysfunctional individual market and a much smaller Medicaid population with many more uninsured people. Once again, Republicans and Democrats continue to debate specifics – rather than deal with differences in beliefs – in an evidence-free brawl.</p><img src="https://counter.theconversation.com/content/80943/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>J.B. Silvers does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Republicans have had a hard time dismantling the Affordable Care Act, despite their promises. That could be because they are operating under certain beliefs about health care that are not accurate.J.B. Silvers, Professor of Health Finance, Weatherhead School of Management & School of Medicine, Case Western Reserve UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/798192017-06-29T23:50:27Z2017-06-29T23:50:27ZHow bills to replace Obamacare would especially harm women<figure><img src="https://images.theconversation.com/files/176287/original/file-20170629-21076-nfnuql.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A woman speaks up at a town hall gathering with Sen. Lindsey Graham (R-South Carolina) in March 2017.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Health-Overhaul-Town-Hall-Graham/bf0a5459ad374d22b1db0ff66600343d/36/0">Mark Crammer/AP</a></span></figcaption></figure><p>As members of Congress are heading back to their districts over Fourth of July break, the future of the Affordable Care Act (ACA), America’s health care system and millions of Americans continues to hang in the balance.</p>
<p>While the House and Senate version of a proposed ACA repeal differ in the details, their broad outlines essentially boil down to three major items.</p>
<p>Both essentially roll back the Medicaid expansion enacted in the ACA that has benefited more than 10 million Americans.</p>
<p>Both significantly reduce funding for the entire Medicaid program that currently benefits 75 million Americans. </p>
<p>And both significantly roll back insurance market regulations that have benefited all Americans wherever they get their insurance. </p>
<p>If these bills become law, more than 20 million Americans would lose coverage over the next 10 years, according to <a href="https://www.cbo.gov/publication/52849">estimates from the nonpartisan Congressional Budget Office</a>. All but the richest Americans will be worse off.</p>
<p>However, one of the most detrimentally affected demographics is actually America’s largest demographic group: America’s women, who would see reductions in coverage, benefits and access.</p>
<p>Much of my <a href="http://simonfhaeder.wixsite.com/home/academic">academic work over the past seven years</a> has focused on the Affordable Care Act. However, as a son, husband and father, whose wife has been previously denied insurance, my concerns are also deeply personal. Policies that are bad for women are bad for all of America.</p>
<h2>Obtaining coverage</h2>
<p>Obtaining insurance coverage has long been challenging for women, as their rates of employer-sponsored insurance have <a href="http://www.kff.org/womens-health-policy/fact-sheet/medicaids-role-for-women/">traditionally trailed those of men significantly</a>.</p>
<p>Not surprisingly, the most dramatic and significant change for women under the ACA, or Obamacare, occurred through the expansion of coverage. Overall the uninsured rate among women fell from <a href="http://files.kff.org/attachment/Issue-Brief-Ten-Ways-That-the-House-American-Health-Care-Act-Could-Affect-Women">17 to 11 percent by 2015</a>. Particularly dramatic were the changes for <a href="http://files.kff.org/attachment/Issue-Brief-Ten-Ways-That-the-House-American-Health-Care-Act-Could-Affect-Women">women of color and those of low socioeconomic standing.</a></p>
<p>One major vehicle for the increase was the expansion of the Medicaid program. Today, <a href="http://files.kff.org/attachment/Issue-Brief-Ten-Ways-That-the-House-American-Health-Care-Act-Could-Affect-Women">20 percent of American women</a> receive coverage through the program. The program serves as the <a href="https://theconversation.com/not-just-for-the-poor-the-crucial-role-of-medicaid-in-americas-health-care-system-78582">crucial backbone for America’s health care system</a>.</p>
<p>In addition, <a href="http://www.kff.org/womens-health-policy/fact-sheet/womens-health-insurance-coverage-fact-sheet/">close to nine million women</a> obtained health insurance coverage in the individual market reformed under the ACA.</p>
<p>Finally, the ACA allowed more than <a href="https://nwlc.org/resources/women-and-health-care-law-united-states/">3.1 million young adults</a> to remain on their parents’ health insurance until age 26.</p>
<h2>Lowering costs</h2>
<p>The availability of insurance coverage is only a first step. Individuals must be able to afford that coverage. While far from perfect, the ACA provided significant funding for women in this regard.</p>
<p>For those women obtaining coverage through Medicaid, <a href="http://files.kff.org/attachment/Fact-Sheet-Medicaids-Role-for-Women">premium and out-of-pocket costs were strictly limited or nonexistent</a>.</p>
<p>Those women who obtained coverage on the <a href="http://jhppl.dukejournals.org/content/early/2015/01/22/03616878-2882219.abstract">ACA’s insurance marketplaces</a> and whose income fell below 400 percent of poverty were eligible for insurance premium subsidies. </p>
<p>For those falling below 250 percent of poverty, <a href="http://onlinelibrary.wiley.com/doi/10.1111/puar.12065/abstract">subsidies to pay for out-of-pocket costs were also available</a>, in addition to premium subsidies. Even for those above the cutoff, the ACA strictly limited annual out-of-pocket costs.</p>
<p>The ACA also sought greater gender equity. As a result, it banned the prevalent practice of gender rating, the practice of charging women higher premiums solely based on their gender. Indeed, in most states it was even common to <a href="https://www.nwlc.org/sites/default/files/pdfs/nwlc_2012_turningtofairness_report.pdf">charge a male smoker less than a female nonsmoker</a> before passage of the ACA.</p>
<p>Finally, the ACA also facilitates access to services by eliminating out-of-pocket costs for preventive services including mammograms and colonoscopies, well-woman visits, vaccinations, domestic and interpersonal violence screening and counseling.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/176285/original/file-20170629-26970-95zbj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/176285/original/file-20170629-26970-95zbj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/176285/original/file-20170629-26970-95zbj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/176285/original/file-20170629-26970-95zbj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/176285/original/file-20170629-26970-95zbj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/176285/original/file-20170629-26970-95zbj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/176285/original/file-20170629-26970-95zbj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The Affordable Care Act pays for preventive services, including mammogram screenings for women.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/happy-woman-looking-doctor-while-undergoing-607144922?src=DoSYX2GufwuY9FDK9l-9qg-1-7">Tyler Olson/www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>The preventive services provisions have proven crucial for all women in America. Annually, <a href="https://obamacarefacts.com/obamacare-womens-health-services/">six million women</a> receive mammograms through Medicare free of charge. <a href="https://obamacarefacts.com/obamacare-womens-health-services/">Forty-seven million privately insured women</a> are also eligible for the free service.</p>
<p>An <a href="https://nwlc.org/resources/women-and-health-care-law-united-states/">estimated 27 million nonelderly women received preventive services without a co-payment in 2011 and 2012</a>. An additional <a href="https://nwlc.org/resources/women-and-health-care-law-united-states/">38 million women with Medicare</a> received preventive services at no additional cost in 2011.</p>
<h2>Benefits and services</h2>
<p>Some of the most crucial advances from the ACA for women came in the form of insurance market reforms. </p>
<p>For the first time, women could no longer be denied coverage for <a href="https://theconversation.com/how-pre-existing-conditions-became-front-and-center-in-health-care-vote-77138">preexisting conditions</a> such as a C-section, being a survivor of breast or cervical cancer, or having received medical treatment for domestic or sexual violence.</p>
<p>Insurers were also required to provide comprehensive coverage to women because insurance plans have to include the so-called <a href="https://theconversation.com/essential-health-benefits-suddenly-at-center-of-health-care-debate-but-what-are-they-75125">Essential Health Benefits</a>. These minimum required benefits include such crucial components of health care as prescription drugs, inpatient care, mental health and substance abuse services, and pediatric oral and vision care. </p>
<p>For those women eligible for Medicaid, <a href="http://files.kff.org/attachment/Fact-Sheet-Medicaids-Role-for-Women">they now gained access to a comprehensive set of health benefits</a>. </p>
<p>Finally, the ACA eliminated annual and lifetime benefit limits for everyone. </p>
<h2>Helping pregnant women and mothers</h2>
<p>While beneficial for all women, the ACA has been particularly helpful for <a href="http://www.healthpolicyjrnl.com/article/S0168-8510(14)00260-7/abstract">mothers and pregnant women</a>. In addition to providing coverage and reducing costs, the ACA also guaranteed mothers and pregnant women access to crucial benefits.</p>
<p>Under the <a href="http://www.healthpolicyjrnl.com/article/S0168-8510(14)00260-7/abstract">Essential Health Benefit provisions</a>, insurers had to provide coverage for pregnancy, maternity and newborn care. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/176286/original/file-20170629-16069-z58qsp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/176286/original/file-20170629-16069-z58qsp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/176286/original/file-20170629-16069-z58qsp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/176286/original/file-20170629-16069-z58qsp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/176286/original/file-20170629-16069-z58qsp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/176286/original/file-20170629-16069-z58qsp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/176286/original/file-20170629-16069-z58qsp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Maternity benefits are costly, but the Affordable Care Act brought their costs down.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pregnant-woman-doctor-hospital-388590370?src=LnkQko4fQ1kVFzHh_2vIpQ-1-11">Africa Studio/www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>With the premium cost of maternity care estimated at <a href="https://www.americanprogress.org/issues/healthcare/news/2017/06/20/434670/senate-health-care-bill-drive-coverage-costs-maternity-care-mental-health-substance-use-disorder-treatment/">more than US$17,000</a>, these guarantees were undeniably important. Not surprisingly, previously only <a href="https://nwlc.org/resources/women-and-health-care-law-united-states/">12 percent of individual market plans</a> included maternity benefits.</p>
<p>Moreover, women are able to access these services because preventive and prenatal services are now covered free of charge.</p>
<p>Insurers are now required to provide new mothers with equipment to extract breast milk and the support services to do so. In addition, employers are now required to provide the time and appropriate space for working women to extract the milk.</p>
<p>Finally, the ACA also supports women in planning their families. One important component was the elimination of out-of-pocket costs for contraception reducing the number of women who had to shoulder that burden from <a href="http://files.kff.org/attachment/Issue-Brief-Ten-Ways-That-the-House-American-Health-Care-Act-Could-Affect-Women">more than 20 percent to 3 percent</a>.</p>
<h2>Changes under the Republican proposals</h2>
<p>Famously excluding both women and Democrats from their secret deliberations, it is perhaps not surprising that the Senate repeal and replace proposal is particularly damaging to women’s health. While all Americans will be affected by the change, the damage for America’s women is particularly striking, as the <a href="https://www.cbo.gov/publication/52849">just-released CBO score</a> confirmed.</p>
<p>Rolling back coverage expansions will force millions of women into uninsurance. Eliminating financial support will reduce access to insurance coverage and services. </p>
<p>And undoing insurance market reforms will eliminate crucial benefits from women’s health plans and prevent them from purchasing adequate insurance coverage that fulfills their health needs. </p>
<p>Cuts to Planned Parenthood will reduce access to crucial reproductive and health services that have nothing to do with abortions.</p>
<p>Because of congressional restrictions, neither the Senate nor the House bill can fully undo the ACA. Yet the detrimental effect of a Republican bill’s passage on Americans is now well-established. </p>
<p>Moreover, we should not forget that <a href="https://theconversation.com/how-trump-and-tom-price-can-kill-obamacare-without-the-senate-76489">further regulatory actions</a> and the <a href="https://theconversation.com/beyond-the-cbo-score-how-trump-budget-and-the-ahca-are-dismantling-americas-safety-net-78308">Trump administration’s budget</a> are bound to further reduce coverage and eliminate benefits for male and female Americans alike.</p>
<p>Without the crucial protections of the ACA, America’s women – our mothers, grandmothers, wives, daughters, sisters, neighbors and friends – will be worse off. So will the rest of America.</p><img src="https://counter.theconversation.com/content/79819/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Almost nine million women gained insurance coverage from the Affordable Care Act. Here’s why women could be set back by Republican bills to undo the ACA.Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/799762017-06-23T01:15:43Z2017-06-23T01:15:43ZHow to make sense of the Senate health care bill: 4 essential reads<figure><img src="https://images.theconversation.com/files/175276/original/file-20170622-13061-z8pclp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Senate Majority Leader Mitch McConnell (R-Kentucky) smiles after he unveiled the Senate health care bill on June 22, 2017. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/APTOPIX-Congress-Health-Overhaul/88619c7a54af46edb7dd293eb93931bf/5/0">Scott Applewhite/AP</a></span></figcaption></figure><p><em>Editor’s note: The following is a roundup of archival stories related to the health care bill presented by Senate Republicans June 22, 2017.</em></p>
<p>When President Trump ran on a promise to “repeal and replace the disaster that is Obamacare,” he had plenty of support from congressional Republicans. They had tried dozens of times to strike down President Obama’s signature health care law, but so long as Obama was in office, he could block their efforts. </p>
<p>That was then, and this is now an entirely different era. </p>
<p>Stymied <a href="https://theconversation.com/essential-health-benefits-suddenly-at-center-of-health-care-debate-but-what-are-they-75125">previously</a>, the Republican-led Congress and Trump are determined to enact a new health care law. They moved another step closer on June 22, when Senate Majority Leader Mitch McConnell (R-Kentucky) unveiled the Senate plan.</p>
<p>While it is a modified version of a plan the House passed in May, the Senate bill retains many of the House bill’s provisions. Republican sponsors and backers say it softens the blow of some of the previous bill’s provisions that could result in people becoming uninsured by extending the period over which the changes would be enacted. Opponents are saying it only extends the time for enacting changes so that senators who will be up for reelection in six years might be spared the ire of voters who have lost their insurance.</p>
<p>Now that the Senate has revealed its plan, we’ve gone back into our archives to identify and explain the key issues of the health care law, including Medicaid expansion, the individual mandate and essential health benefits. </p>
<h2>One of the biggies: Medicaid rollback</h2>
<p>One of the key provisions of the Affordable Care Act, or Obamacare, was the expansion of Medicaid coverage to adults whose incomes are so low that they could not afford to buy insurance. Before expansion, most states’ Medicaid programs paid for insurance coverage for children, disabled adults and seniors’ nursing care. </p>
<p>The federal government provided money to the states to fund the expansion, but 19 states refused the money – and thus the expansion.</p>
<p>The new bill would phase out Medicaid expansion in the states that participated. That could be a disastrous move, many health care advocates fear, even though Republicans view that as a way to control costs. </p>
<p>West Virginia University public policy scholar Simon Haeder explained in a <a href="https://theconversation.com/not-just-for-the-poor-the-crucial-role-of-medicaid-in-americas-health-care-system-78582">June 7, 2017 article</a> that Medicaid long ago ceased to be a program for the poor and instead “provides the backbone of America’s health care system.” </p>
<blockquote>
<p>“Indeed, it is the largest single payer in the American health care system, covering more than 20 percent of the population. This amounts to 75 million American children, pregnant women, parents, single adults, disabled people and seniors.</p>
<p>"To put this in perspective, this is about the same number of individuals as the nation’s two largest commercial insurers combined. Roughly half of all enrollees are children.”</p>
</blockquote>
<p>University of Southern California health economist Darius Lakdawalla, University of Chicago economist Anup Malani and Stanford University professor of medicine Jay Bhattacharya explained that Medicaid is far from a perfect program, however, and <a href="https://theconversation.com/why-america-needs-a-do-over-on-medicaid-reform-75524">could stand an “do-over.”</a> Low reimbursement rates to doctors are a big problem, they wrote. </p>
<blockquote>
<p>“Medicaid provides lower reimbursements to physicians than private insurance or Medicare, the federal health program for elderly and disabled Americans. The result: fewer physicians accepting Medicaid coverage and fewer choices for Medicaid beneficiaries.</p>
<p>"Prior studies suggest that about one-third of physicians nationwide refuse to accept new patients on Medicaid, and this problem is even worse in urban areas.</p>
<p>"Rural areas have their own problems with the program. Their residents are poorer and more likely to be on Medicaid. The prevalence of Medicaid coverage, and its stingier reimbursements, is one reason why hospitals in rural areas have closed down.”</p>
</blockquote>
<h2>Mandate gets nixed</h2>
<p>Republicans detested one provision of Obamacare so much that they contested it – all the way to the Supreme Court. This is the so-called individual mandate, or the requirement that all people above a certain income buy insurance or else face a penalty. Opponents of the mandate said the requirement was unconstitutional. In a 5-4 decision on June 28, 2012, the court disagreed, upholding the mandate and drawing the wrath of Republicans, many of whom turned on Chief Justice John Roberts, who authored the majority opinion.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/175278/original/file-20170622-12021-1emm4gi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/175278/original/file-20170622-12021-1emm4gi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=890&fit=crop&dpr=1 600w, https://images.theconversation.com/files/175278/original/file-20170622-12021-1emm4gi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=890&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/175278/original/file-20170622-12021-1emm4gi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=890&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/175278/original/file-20170622-12021-1emm4gi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1118&fit=crop&dpr=1 754w, https://images.theconversation.com/files/175278/original/file-20170622-12021-1emm4gi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1118&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/175278/original/file-20170622-12021-1emm4gi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1118&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Chief Justice John Roberts, a George W. Bush appointee, drew rebukes from conservatives after the 2012 ruling on Obamacare upheld the individual mandate.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Supreme-Court/f31bf42cfbd54c5fb9d357e9770816ab/41/0">J. Scott Applewhite/AP</a></span>
</figcaption>
</figure>
<p>The Senate bill, like its sister House bill, would kill that mandate. </p>
<p>But the purpose of the mandate is to bring healthy people into the insurance market, health policy scholars have written in The Conversation. Insurers need those healthy people to lower risk and buffer against the higher costs associated with sicker people. And without such a mandate, healthy people will not enroll, and the marketplace would crumble. </p>
<p>Georgia State University scholar <a href="https://theconversation.com/could-the-individual-insurance-market-collapse-in-some-states-heres-how-that-could-happen-74354">Bill Custer explained</a> it this way in a March 2017 piece for The Conversation:</p>
<blockquote>
<p>“But when healthy individuals choose not to purchase health insurance, insurers are left with costs greater than their premium income. That forces insurers to increase their premiums, which in turn leads healthier individuals to drop coverage increasing average claims costs.</p>
<p>"An adverse selection death spiral results when insurers can’t raise their premiums enough to cover their costs and they leave the market.”</p>
</blockquote>
<h2>Essential health benefits would change</h2>
<p>Obamacare required that insurers provide coverage for certain services deemed to be basic, or essential, to good health. The goal was to prevent insurers from offering pared-back plans that would leave consumers empty-handed in time of medical need. These included such things as maternity benefits, emergency care and hospitalization. </p>
<p>This provision has long irked conservative Republicans, who view it as not only costly but also an example of governmental intrusion. Like the House bill, the Senate bill allows states more choice about these essential health benefits.</p>
<p>West Virginia’s Simon Haeder explained in a March 2017 piece how the <a href="https://theconversation.com/essential-health-benefits-suddenly-at-center-of-health-care-debate-but-what-are-they-75125">essential health benefits</a> came about:</p>
<blockquote>
<p>“Even when essential services requirements were in place before the ACA, they were often fairly weak and allowed insurers to make coverage optional or to cap allowable benefits. This greatly affected what and how much care people had access to.</p>
<p>"For example, 62 percent of individuals in the individual market lacked maternity coverage and 34 percent lacked coverage for substance abuse disorder treatment.</p>
<p>"Thus, the EHB provisions were included in the ACA, for many reasons. First, the ACA was intended to provide coverage that offers viable protection against some of the most basic health care costs Americans experience.”</p>
</blockquote><img src="https://counter.theconversation.com/content/79976/count.gif" alt="The Conversation" width="1" height="1" />
The Senate released its new health care bill on June 22, 2017, and it differs slightly from a bill passed by the House in May. Read what our experts have written in recent months about key pieces.Lynne Anderson, Senior Health + Medicine Editor, The Conversation, USLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/785822017-06-08T02:36:32Z2017-06-08T02:36:32ZNot just for the poor: The crucial role of Medicaid in America’s health care system<figure><img src="https://images.theconversation.com/files/172780/original/file-20170607-5408-1s5sis7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Nurse Jane Kern administers medicine to patient Lexi Gerkin in Brentwood, New Hampshire. Lexi is one of thousands of severely disabled or ill children covered by Medicaid, regardless of family income.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/Search?query=Medicaid&ss=10&st=kw&entitysearch=&toItem=15&orderBy=Newest&searchMediaType=excludecollections">Charles Krupa/AP</a></span></figcaption></figure><p>Despite many assertions to <a href="http://thehill.com/homenews/senate/336493-lindsey-graham-i-dont-think-gop-can-pass-healthcare-bill-this-year">the contrary</a>, Senate leaders are <a href="https://www.vox.com/policy-and-politics/2017/6/6/15750078/voxcare-new-factions-of-senate-health-care-debate">now saying</a> they want to vote on the <a href="https://www.congress.gov/bill/115th-congress/house-bill/1628">replacement bill for Obamacare</a> before the month is out. </p>
<p>Front and center is the planned transformation of America’s Medicaid program, which covers 20 percent of Americans and provides the backbone of America’s health care system.</p>
<p>As a professor of public policy, I have <a href="http://simonfhaeder.wixsite.com/home/academic">written extensively</a> about the <a href="https://www.cambridge.org/core/journals/journal-of-policy-history/article/inching-toward-universal-coverage-statefederal-healthcare-programs-in-historical-perspective/E94A03DD1F60F9DCBE3DDE9728DA3224">American health care system</a> and the <a href="http://jhppl.dukejournals.org/content/40/2/281">Affordable Care Act</a>. </p>
<p>Living in West Virginia, perhaps the nation’s poorest state, I have also seen the benefits of the ACA’s Medicaid expansion since 2014. </p>
<p>To understand how the ACHA’s proposed changes to Medicaid would affect people and our health care system, let’s look more closely at the program.</p>
<h2>What is Medicaid?</h2>
<p>Created in 1965, Medicaid today provides health care services for <a href="http://www.kff.org/health-reform/state-indicator/total-monthly-medicaid-and-chip-enrollment/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">75 million Americans</a>. It is jointly administered by the federal government and the states. The federal government pays at <a href="http://kff.org/medicaid/state-indicator/federal-matching-rate-and-multiplier/">least 50 percent</a> of the costs of the program. For particularly poor states, the federal government’s contribution <a href="http://kff.org/medicaid/state-indicator/federal-matching-rate-and-multiplier/">can exceed 75 percent</a>.</p>
<p>Medicaid was initially envisioned to provide medical assistance only to individuals <a href="https://kaiserfamilyfoundation.files.wordpress.com/2010/06/7334-05.pdf">receiving cash welfare benefits</a>. Over time, the program has been significantly expanded in terms of benefits and eligibility to make up for the growing shortcomings of private insurance markets, including <a href="http://www.kff.org/private-insurance/issue-brief/trends-in-employer-sponsored-insurance-offer-and-coverage-rates-1999-2014/">rapidly growing premiums and increasing rates of uninsurance</a>. </p>
<p>Like all health care programs, spending on Medicaid has increased dramatically since its inception in 1965. Today, we are spending about <a href="http://kff.org/medicaid/state-indicator/total-medicaid-spending/">US$550 billion annually</a>. This compares to about <a href="https://kaiserfamilyfoundation.files.wordpress.com/2013/01/8152.pdf">$300 billion in 2007</a>. </p>
<h2>What does Medicaid do?</h2>
<p>As Medicaid evolved, it has become more than just a program for America’s poor. Indeed, it is the largest single payer in the American health care system, <a href="http://www.kff.org/other/state-indicator/total-population/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">covering more than 20 percent of the population</a>. This amounts to <a href="http://files.kff.org/attachment/Fact-Sheet-Medicaid-Pocket-Primer">75 million American children, pregnant women, parents, single adults, disabled people and seniors</a>.</p>
<p>To put this in perspective, this is about the same number of individuals as <a href="http://www.healthcarefinancenews.com/news/anthem-membership-overtakes-unitedhealthcare-one-count">the nation’s two largest commercial insurers combined</a>. </p>
<p>Roughly half of all enrollees <a href="http://files.kff.org/attachment/Fact-Sheet-Medicaid-Pocket-Primer">are children</a>. </p>
<p>Medicaid also pays for about <a href="https://www.abqjournal.com/977267/nm-has-highest-rate-of-medicaidcovered-births.html">50 percent of births in the U.S.</a> In some states like New Mexico, Arkansas, Wisconsin and Oklahoma, close to <a href="https://www.abqjournal.com/977267/nm-has-highest-rate-of-medicaidcovered-births.html">two-thirds of births are paid for by Medicaid</a>. </p>
<p>Medicaid helps many Americans who are generally not considered “needy.” For example, the <a href="http://files.kff.org/attachment/report-medicaid-financial-eligibility-for-seniors-and-people-with-disabilities-in-2015">Katie Beckett program</a> provides support to families with children with significant disabilities without regard to parental income. </p>
<p>Medicaid is also critical for elderly Americans. It is Medicaid – not the federally run insurance program for the elderly, Medicare – that is the largest payer for long-term care in the United States. These services include, for example, <a href="http://www.kff.org/medicaid/report/medicaid-and-long-term-services-and-supports-a-primer/">nursing facility care, adult daycare programs, home health aide services and personal care services</a>. It pays for roughly <a href="http://kff.org/medicaid/report/medicaid-and-long-term-services-and-supports-a-primer/">50 percent of all long-term care expenses and about two-thirds of nursing home residents</a>. And it also provides help with Medicare premiums for <a href="http://files.kff.org/attachment/Fact-Sheet-Medicaid-Pocket-Primer">about 20 percent of seniors</a>.</p>
<p>Indeed, the vast majority of costs in the Medicaid program, <a href="http://www.pewtrusts.org/en/research-and-analysis/analysis/2015/07/29/state-spending-on-medicaid">about two-thirds, are incurred by elderly or disabled individuals who make up only a quarter of enrollment</a>. </p>
<h2>How did the Affordable Care Act, or Obamacare, change Medicaid?</h2>
<p>One of main components of the Affordable Care Act was the <a href="http://jhppl.dukejournals.org/content/40/2/281">expansion of Medicaid</a> to 138 percent of the Federal Poverty Line (FPL). For a family of four, this amounts to $2,800 per month. </p>
<p>However, the <a href="http://jhppl.dukejournals.org/content/40/2/281">Supreme Court rejected the ACA’s mandatory expansion of Medicaid and made it optional</a>. To date, 31 states and Washington, D.C. have chosen to expand their Medicaid program. Not surprisingly, <a href="http://kff.org/uninsured/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/">the uninsurance rate in those states has dropped significantly more</a> than in states refusing to expand their Medicaid programs.</p>
<p>Nonetheless, Medicaid enrollment increased <a href="http://kff.org/health-reform/state-indicator/medicaid-expansion-enrollment/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">by about 30 percent since the inception of the ACA</a>. </p>
<p>The expansion has also resulted in <a href="http://www.fiercehealthcare.com/population-health/medicaid-expansion-linked-to-better-care-access-better-health">better access and better health</a> for individuals. </p>
<p>It has also helped to <a href="http://www.statenetwork.org/wp-content/uploads/2016/07/State-Network-Manatt-Medicaid-States-Most-Powerful-Tool-to-Combat-the-Opioid-Crisis-July-2016.pdf">fight the nation’s opioid epidemic</a>.</p>
<p>In states that did not expand Medicaid, <a href="http://kff.org/report-section/a-look-at-rural-hospital-closures-and-implications-for-access-to-care-three-case-studies-issue-brief/">hospital closures occurred disportionately</a>.</p>
<h2>What would the Republican-backed AHCA and the Trump budget do to Medicaid?</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/172783/original/file-20170607-21294-1y1r2mq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/172783/original/file-20170607-21294-1y1r2mq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/172783/original/file-20170607-21294-1y1r2mq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/172783/original/file-20170607-21294-1y1r2mq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/172783/original/file-20170607-21294-1y1r2mq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/172783/original/file-20170607-21294-1y1r2mq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/172783/original/file-20170607-21294-1y1r2mq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Tom Price, secretary of the Department of Health and Human Services, whose department includes the oversight of Medicaid, pictured in the Rose Garden the day House Republicans passed a bill that would overhaul Medicaid.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Trump-Congress-Health-Care/a130d64a97514786b6e584fa4d1176e8/19/0">Evan Vucci/AP</a></span>
</figcaption>
</figure>
<p>Overall, the <a href="https://www.congress.gov/bill/115th-congress/house-bill/1628">American Health Care Act</a> cuts more than $800 billion from Medicaid by 2026. The cuts focus on two major components.</p>
<p>First, the AHCA significantly reduces funding for the Medicaid expansion under the Affordable Care Act. These changes reduce the federal government’s contribution from 90 percent to an <a href="https://www.medicaid.gov/medicaid/financing-and-reimbursement/">average of 57 percent</a>. The large associated costs for states
<a href="http://www.wvgazettemail.com/gazette-op-ed-commentaries/20170513/simon-f-haeder-time-to-be-honest-american-health-care-act-bad-for-wv">would virtually eliminate the expansion in most if not all states</a>. </p>
<p>However, the American Health Care Act goes further. Specifically, it alters the funding mechanism for the entire Medicaid program. Instead, it provides a set amount of funding per individual enrolled in Medicaid. In doing so, it ends the federal government’s open-ended commitment to providing health care to America’s neediest populations. </p>
<p>Over time, these per capita payment are adjusted based on the Medical Consumer Price Index. In states like West Virginia, these increases <a href="http://www.wvgazettemail.com/gazette-op-ed-commentaries/20170513/simon-f-haeder-time-to-be-honest-american-health-care-act-bad-for-wv">will not keep pace with rising costs for the state’s sick and disabled</a>. </p>
<p>In addition to the more than $800 billion in cuts to Medicaid under the AHCA, the <a href="https://www.documentcloud.org/documents/3728643-Putting-America-s-Health-First-FY-2018-President.html">proposed budget by President Trump</a> would further cut Medicaid by more than $600 billion over ten years. </p>
<p>One major way to achieve this is to further reduce the <a href="http://www.kff.org/medicaid/fact-sheet/presidents-2018-budget-proposal-reduces-federal-funding-for-coverage-of-children-in-medicaid-and-chip/">growth rate of the per capita payments</a>. </p>
<h2>What would be the effects of dismantling Medicaid?</h2>
<p>Both the American Health Care Act and the Trump budget would be challenging for the program. In combination, I believe they would be truly devastating.</p>
<p>The cuts would force millions of Americans into uninsurance. Confronted with medical needs, these Americans will be forced to choose between food and shelter and medical treatment for themselves and their families. They would also <a href="http://www.consumerreports.org/personal-bankruptcy/how-the-aca-drove-down-personal-bankruptcy/">force millions of Americans into medical bankruptcy</a>, similar to the situation prior to the ACA. </p>
<p>The cuts would also affect the broader American health care system. They would create incredible burdens on American hospitals and other safety net providers. Many of them are already operating <a href="https://www.ruralhealthweb.org/news/nearly-700-rural-hospitals-at-risk-of-closing">on very thin margins</a>. </p>
<p>Medicaid is particularly important in keeping doors open at <a href="http://kff.org/report-section/a-look-at-rural-hospital-closures-and-implications-for-access-to-care-three-case-studies-issue-brief/">rural</a>, <a href="https://essentialhospitals.org/tag/medicaid/">inner-city and essential service hospitals</a>.</p>
<p>The cuts would cause tremendous burdens for million of Americans <a href="http://www.kff.org/medicaid/report/medicaid-and-long-term-services-and-supports-a-primer/">with disabilities and their families</a>. </p>
<p>They would shrink the program <a href="https://www.nytimes.com/interactive/2017/05/24/us/politics/trump-medicaid-budget-cuts.html?_r=0">virtually in half</a> over the next decade. </p>
<p>Unable to raise the necessary funds, states will be forced to <a href="http://www.wvgazettemail.com/gazette-op-ed-commentaries/20170513/simon-f-haeder-time-to-be-honest-american-health-care-act-bad-for-wv">cut either eligibility, benefits or both</a>.</p>
<p>In my view, both the American Health Care Act and the proposed budget by the Trump administration will cause dramatic, avoidable harm to millions of our families, friends, neighbors and communities.</p><img src="https://counter.theconversation.com/content/78582/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>As Republicans seek to repeal Obamacare, they have added an overhaul of Medicaid to their plans. Here’s a look at the program and the surprising number of people who would be affected by cuts.Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/783082017-05-25T16:02:46Z2017-05-25T16:02:46ZBeyond the CBO score: How Trump Budget and the AHCA are dismantling America’s safety net<figure><img src="https://images.theconversation.com/files/171018/original/file-20170525-23224-nbrwvx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">President Trump and House Speaker Paul Ryan, to his left, celebrating the House passage of the AHCA on May 4. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Trump-Congress-Health-Care/73cecd998d2f4a7fb66082493c523a1b/17/0">Evan Vucci/AP</a></span></figcaption></figure><p>The Congressional Budget Office (CBO) on May 24 released its <a href="https://www.cbo.gov/publication/52752">long-awaited analysis</a> of the <a href="https://www.congress.gov/bill/115th-congress/house-bill/1628">American Health Care Act</a> (AHCA) passed by the House of Representatives three weeks ago. </p>
<p>While the score was not dramatically different from an earlier one, it nonetheless drew a significant amount of news coverage. Countless articles talk about the AHCA’s dramatic effects on insurance coverage and premiums.</p>
<p>However, this focus is decidedly too narrow and missed the larger endeavor by President Trump and Speaker Paul Ryan to initiate a dramatic disinvestment from the nation’s disadvantaged, particularly in terms of health care. </p>
<p>Working in one of the nation’s poorest states, West Virginia, I encounter the challenges of poverty firsthand. It complements my academic work on the <a href="http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=9914748&fulltextType=RA&fileId=S0898030615000330">historic development of the American safety net</a> and the <a href="http://search.proquest.com/openview/bf39b86775e074685e579cd03284e9f7/1.pdf?pq-origsite=gscholar&cbl=18750&diss=y">historic role of public hospitals</a>. The combination of the AHCA and the Trump administration’s budget would hollow out America’s safety net that has evolved since the New Deal and the Great Society.</p>
<h2>The Congressional Budget Office and the American Health Care Act</h2>
<p>The <a href="https://www.cbo.gov/">Congressional Budget Office (CBO)</a> is a nonpartisan congressional agency created in the early 1970s during the Nixon administration. It was envisioned as a counterweight to the dominance of the executive branch and the president in policymaking, particularly when it comes to budgeting. It was also supposed to infuse policy decisions with nonpartisan, analytical information. The <a href="http://search.proquest.com/openview/bf39b86775e074685e579cd03284e9f7/1?pq-origsite=gscholar&cbl=18750&diss=y">assumption is that policymaking is better</a> when it is informed by facts and when we are aware of the effects of the legislation before passing it.</p>
<p>By and large, the CBO has lived up to its expectations. While far from perfect in its projections, it is generally held in high regard by politicians and scholars alike. As such, it has held a dominant role in some of the nation’s major legislative efforts, including the Clinton-era <a href="https://books.google.com/books?id=e4MYDQAAQBAJ&pg=PT104&lpg=PT104&dq=cbo+score+health+security+act+clinton&source=bl&ots=5-k10nsMYB&sig=hCNlQ_Ak6u_BpcBFsnQ7gVB8g0Q&hl=en&sa=X&ved=0ahUKEwiX8OCtionUAhXLD8AKHZgMAdIQ6AEISzAH#v=onepage&q=cbo%20score%20">Health Security Act</a>, the <a href="https://www.cbo.gov/topics/health-care/affordable-care-act">Affordable Care Act</a> and now the <a href="https://www.cbo.gov/publication/52486">American Health Care Act</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/171020/original/file-20170525-23224-o7ko8p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/171020/original/file-20170525-23224-o7ko8p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/171020/original/file-20170525-23224-o7ko8p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/171020/original/file-20170525-23224-o7ko8p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/171020/original/file-20170525-23224-o7ko8p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/171020/original/file-20170525-23224-o7ko8p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/171020/original/file-20170525-23224-o7ko8p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">President Trump and Seema Verma, administrator for the Center for Medicare and Medicaid Services, at March meeting in which work requirements for Medicaid were discussed.</span>
<span class="attribution"><span class="source">Evan Vucci/AP</span></span>
</figcaption>
</figure>
<p>In March, the CBO had scored a previous version of the <a href="https://www.cbo.gov/publication/52486">American Health Care Act</a>, saying 24 million Americans would lose their insurance under the AHCA. The score also showed that insurance premiums in the individual market <a href="https://www.brookings.edu/blog/up-front/2017/03/16/how-will-the-house-gop-health-care-bill-affect-individual-market-premiums/">would actually increase</a> because fewer benefits would be included. </p>
<p>At the same time, the AHCA would provide a massive tax cut to America’s wealthiest and reduce the federal deficit just over US$100 billion over 10 years. It would do so because of massive cuts to Medicaid and the ACA’s insurance premium subsidies.</p>
<p>However, the version ultimately passed by the House of Representatives had not been scored until yesterday. Some have argued that Speaker Paul Ryan (R-WI) <a href="http://thehill.com/policy/healthcare/health-reform-implementation/331954-ex-cbo-head-voting-with-no-repeal-score">deliberately rushed the bill to a vote to avoid being confronted</a> with what experts expect to be abysmal numbers by the CBO.</p>
<p>And the numbers were bad indeed. The most recent <a href="https://www.cbo.gov/publication/52752">CBO estimate</a> expects 23 million Americans to lose insurance coverage. Moreover, it shows reduced savings, higher premiums if benefit design and age distribution remain constant, and inadequate protections for Americans with preexisting conditions.</p>
<p>Importantly, the CBO also expects one-sixth of the nation’s individual insurance market to collapse due to the newly added provisions in the AHCA allowing states to eliminate the ACA’s <a href="https://theconversation.com/essential-health-benefits-suddenly-at-center-of-health-care-debate-but-what-are-they-75125">Essential Health Benefits</a> and charge higher premiums for <a href="https://theconversation.com/how-pre-existing-conditions-became-front-and-center-in-health-care-vote-77138">individuals with preexisting conditions</a>. Overall, 51 million Americans are expected to be without insurance in 2026.</p>
<h2>The bigger picture: Disinvesting in the disadvantaged</h2>
<p>Not surprisingly, the focus of countless media articles and TV news has been on the CBO’s scoring of the American Health Care Act. However, while important, this loses sight of larger, more concerning developments.</p>
<p>Indeed, the CBO’s dire prediction for America’s uninsured under the American Health Care Act is made significantly worse by the <a href="https://www.whitehouse.gov/sites/whitehouse.gov/files/omb/budget/fy2018/2018_blueprint.pdf">Trump administration’s recently released budget</a>.</p>
<p>While the AHCA’s drastic $834 billion cuts to the Medicaid program are estimated to cost 14 million Americans their coverage, the Trump budget will cut an additional $610 billion. This would basically slash the current Medicaid program in half and destroy a mainstay of America’s safety net since the Great Society.</p>
<p>While the dramatic cuts to the Medicaid program will affect more than 70 million Americans, there is more. The bipartisan and popular Children’s Health Insurance Program (CHIP) is slated for a 21 percent cut as well as significant reductions in eligibility. Some states like Arizona and West Virginia have automatic triggers that would eliminate CHIP with these funding reductions.</p>
<p>Moreover, the proposed budget cuts or eliminates funding to agencies and programs helping the most vulnerable in our communities beyond the immediate provision of health care.</p>
<p>It cuts funding to the <a href="https://www.samhsa.gov/">Substance Abuse and Mental Health Services Administration</a> (SAMHSA), tasked with reducing the ill effects of substance abuse and mental illness.</p>
<p>It cuts funding to the <a href="https://www.cdc.gov/ncbddd/index.html">National Center on Birth Defects and Developmental Disabilities</a> (NCBDDD), which addresses birth defects and improves the health of individuals with disabilities.</p>
<p>It cuts funding to the National Asthma Control Program (NACP), intended to <a href="https://www.cdc.gov/asthma/nacp.htm">“help the millions of people with asthma in the United States gain control over their disease.”</a></p>
<p>It cuts funding to the <a href="https://www.fns.usda.gov/snap/supplemental-nutrition-assistance-program-snap">Supplemental Nutrition Assistance Program</a> (SNAP), which provides food for million of Americans.</p>
<p>It cuts funding to the <a href="https://www.fns.usda.gov/wic/women-infants-and-children-wic">Special Supplemental Nutrition Program for Women, Infants, and Children</a> (WIC), which provides nutritious food for pregnant women, young children, and half of all infants in the country.</p>
<p>It cuts funding to the <a href="https://www.arc.gov/">Appalachian Regional Commission</a>, which provides loans to improve sewers and provide safe drinking water in rural Appalachia.</p>
<p>It cuts funding for a number of programs which support rural hospitals and minorities, such as the <a href="https://www.hrsa.gov/ruralhealth/programopportunities/fundingopportunities/?id=b56d4504-7bf6-4f79-b0e8-37b766f2213e">Rural Hospital Outreach Grant</a> and the <a href="https://www.multiplan.com/providers/ruralhealthgrants.cfm">Rural Hospital Flexibility Grant</a>.</p>
<p>It cuts funding for important medical and public health research as places like the <a href="https://www.cdc.gov/">Centers for Disease Control and Prevention</a> (CDC) and the <a href="https://www.nih.gov/">National Institutes of Health</a> (NIH).</p>
<p>The list, unfortunately, goes on. </p>
<h2>Moving forward</h2>
<p>Just months ago, the nation reached a milestone when the uninsured rate fell to a <a href="http://money.cnn.com/2017/03/13/news/economy/uninsured-rate-obamacare/">historic low</a>. Meanwhile, Republicans and Democrats are heatedly debating the future of the nation’s health care system.</p>
<p>What often gets lost in the numbers and the public debate is that they involve people’s lives and livelihoods. With all its shortcomings, the Affordable Care Act has brought relief to millions of Americans who are no longer scared to fall sick.</p>
<p>When a person loses health care, it often means having to choose between food and medications. It means delaying necessary care, exacerbating medical conditions with at times irreversible consequences. </p>
<p>Much remains to be done to improve the American health care system. But the changes proposed by President Trump and Speaker Ryan would reverse decades of gains made for America’s disadvantaged <a href="http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=9914748&fulltextType=RA&fileId=S0898030615000330">since the 1920s</a>. </p>
<p>Perhaps most importantly, both the AHCA and the Trump administration’s budget would cause tremendous amounts of suffering and pain across all of our communities.</p><img src="https://counter.theconversation.com/content/78308/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The CBO analysis of the new health care bill not only shows that tens of millions would lose insurance. It is a major shift in this country’s attitudes and policies toward helping the poor.Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/775912017-05-15T00:07:33Z2017-05-15T00:07:33ZWhy the US does not have universal health care, while many other countries do<figure><img src="https://images.theconversation.com/files/169006/original/file-20170511-32613-edj2t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">House Speaker Paul Ryan walking into the Capitol on May 4, when the House voted narrowly to accept a bill he shepherded to replace Obamacare. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Congress-Rdp/42feb4969aa84e64ae1345633357a69d/39/0">Andrew Harnik/AP</a></span></figcaption></figure><p>The lead-up to the House passage of the American Health Care Act (AHCA) on May 4, which passed by a narrow majority after a failed first attempt, provided a glimpse into just how difficult it is to gain consensus on health care coverage. </p>
<p>In the aftermath of the House vote, many people have asked: Why are politicians struggling to find consensus on the AHCA instead of pursuing universal coverage? After all, <a href="https://www.theatlantic.com/international/archive/2012/06/heres-a-map-of-the-countries-that-provide-universal-health-care-americas-still-not-on-it/259153/">most advanced industrialized countries</a> have universal health care. </p>
<p>As a health policy and politics scholar, I have some ideas. Research from political science and health services points to three explanations. </p>
<h2>No. 1: American culture is unique</h2>
<p>One key reason is the unique political culture in America. As a nation that began on the back of immigrants with an entrepreneurial spirit and without a feudal system to ingrain a rigid social structure, Americans are <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447684/">more likely to be individualistic</a>.</p>
<p>In other words, Americans, and conservatives in particular, have a strong belief in classical liberalism and the idea that the government should play a limited role in society. Given that universal coverage inherently clashes with this belief in individualism and limited government, it is perhaps not surprising that it has never been enacted in America even as it has been enacted elsewhere.</p>
<p>Public opinion certainly supports this idea. Survey research conducted by the <a href="https://www.cambridge.org/core/journals/perspectives-on-politics/article/the-welfare-state-nobody-knows-debunking-myths-about-us-social-policy-and-welfare-discipline-discourse-governance-and-globalization-/5DB1392868DF638547F11B74EF111474">International Social Survey Program</a> has found that a lower percentage of Americans believe health care for the sick is a government responsibility than individuals in other advanced countries like Canada, the U.K., Germany or Sweden.</p>
<h2>No. 2: Interest groups don’t want it</h2>
<p>Even as American political culture helps to explain the health care debate in America, culture is far from the only reason America lacks universal coverage. Another factor that has limited debate about national health insurance is the role of interest groups in influencing the political process. The legislative battle over the content of the ACA, for example, <a href="https://www.publicintegrity.org/2010/02/24/2725/lobbyists-swarm-capitol-influence-health-reform">generated US$1.2 billion in lobbying</a> in 2009 alone.</p>
<p>The insurance industry was a key player in this process, spending over <a href="https://www.publicintegrity.org/2010/02/24/2725/lobbyists-swarm-capitol-influence-health-reform">$100 million to help shape the ACA</a> and keep private insurers, as opposed to the government, as the key cog in American health care.</p>
<p>While recent reports suggest <a href="http://www.cbsnews.com/news/doctors-health-groups-denounce-ahca-health-care-vote/">strong opposition from interest groups</a> to the AHCA, it is worth noting that even when confronted with a bill that many organized interests view as bad policy, universal health care has not been brought up as an alternative. </p>
<h2>No. 3: Entitlement programs are hard in general to enact</h2>
<p>A third reason America lacks universal health coverage and that House Republicans struggled to pass their plan even in a very conservative House chamber is that America’s political institutions make it difficult for massive entitlement programs to be enacted. As policy experts have pointed out in <a href="http://jhppl.dukejournals.org/content/20/2/329.abstract">studies of the U.S. health system,</a> the country doesn’t “have a comprehensive national health insurance system because American political institutions are structurally biased against this kind of comprehensive reform.”</p>
<p>The political system is prone to inertia, and any attempt at comprehensive reform must pass through the obstacle course of congressional committees, budget estimates, conference committees, amendments and a potential veto while opponents of reform publicly bash the bill.</p>
<h2>Bottom line: Universal coverage unlikely to happen</h2>
<p>Ultimately, the United States remains one of the only advanced industrialized nations without a comprehensive national health insurance system and with little prospect for one developing under President Trump or even subsequent presidents because of the many ways America is exceptional.</p>
<p>Its culture is unusually individualistic, favoring personal over government responsibility; lobbyists are particularly active, spending billions to ensure that private insurers maintain their status in the health system; and our institutions are designed in a manner that limits major social policy changes from happening. </p>
<p>As long as the reasons above remain, there is little reason to expect universal coverage in America anytime soon.</p>
<p><em>Editor’s note: this is an updated version of an article that originally ran on October 25, 2016.</em></p><img src="https://counter.theconversation.com/content/77591/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Timothy Callaghan does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Arguments about the AHCA showed deep disagreement on health care coverage. Could this move us toward universal coverage, which some say could be simpler? Don’t hold your breath.Timothy Callaghan, Assistant Professor, Texas A&M University Health Science Center, Texas A&M UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/755242017-05-12T01:20:29Z2017-05-12T01:20:29ZWhy America needs a ‘do-over’ on Medicaid reform<figure><img src="https://images.theconversation.com/files/168661/original/file-20170509-7902-1jwki35.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">President Trump and House Speaker Paul Ryan after the House passed a bill to repeal Obamacare and cut back Medicaid funding. </span> <span class="attribution"><a class="source" href="http://www.newsweek.com/barack-obama-criticizes-responds-republicans-courage-health-care-vote-596093">Evan Vucci</a></span></figcaption></figure><p>One of the most important pieces of the newly passed House health bill is a possible <a href="https://www.nytimes.com/2017/03/15/us/politics/obamacare-repeal-tax-cuts.html">US$800 billion cut over 10 years to Medicaid</a>, the federal program designed to provide insurance coverage to the poor. </p>
<p>That bill, entitled the American Health Care Act (AHCA), rolls back part of the expansion of Medicaid that took place under the Affordable Care Act (ACA) by limiting federal contributions toward state coverage of individuals with <a href="http://www.coveredca.com/PDFs/FPL-chart.pdf">annual incomes above US$16,643 or families of four with annual incomes above $33,948</a>. With the reduction in federal support, states will now have to decide if they can afford to cover adults with incomes just above the federal poverty line. In addition, the AHCA freezes federal spending per Medicaid beneficiary <a href="http://files.kff.org/attachment/Proposals-to-Replace-the-Affordable-Care-Act-Summary-of-the-American-Health-Care-Act">at its 2016 levels</a>.</p>
<p>The bill’s exact financial impact on Medicaid remains uncertain, because the House passed it before the Congressional Budget Office had a chance to evaluate the numbers. The projected $800 billion cut is <a href="https://www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/hr1628.pdf#page=9">taken from a CBO analysis</a> conducted on a prior version of the AHCA. That version as well as the bill passed in May give more control to states to administer Medicaid.</p>
<p>Republican leaders have argued the <a href="https://finance.yahoo.com/news/gop-struggles-explain-ahca-880-093000297.html">current Medicaid system</a> is failing and in need of reform. Democrats, including former President Obama, have charged that the <a href="http://www.newsweek.com/barack-obama-criticizes-responds-republicans-courage-health-care-vote-596093">AHCA harms the well-being of poor</a> and vulnerable groups. </p>
<p>We wholeheartedly agree – with both sides. We question the wisdom of steep cuts to an already underfunded Medicaid system. But the status quo is not working either. </p>
<p>So what should we do?</p>
<h2>The AHCA underfunds an already struggling program</h2>
<p>Medicaid, the federal-state program that provides health coverage to about <a href="http://kff.org/health-reform/state-indicator/total-monthly-medicaid-and-chip-enrollment/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">75 million</a> poor and disabled people, fails to provide them <a href="http://www.heritage.org/health-care-reform/report/studies-show-medicaid-patients-have-worse-access-and-outcomes-the">adequate access</a> to the quality of medical care that other Americans enjoy. </p>
<p>The reason is straightforward: Medicaid provides <a href="https://www.advisory.com/daily-briefing/2016/06/20/low-reimbursement-limit-medicaid-expansion">lower reimbursements</a> to physicians than private insurance or Medicare, the federal health program for elderly and disabled Americans. The result: fewer physicians accepting Medicaid coverage and fewer choices for Medicaid beneficiaries. </p>
<p>Prior studies suggest that about one-third of physicians nationwide refuse to accept new patients on Medicaid, and this <a href="http://content.healthaffairs.org/content/31/8/1673.abstract">problem is even worse in urban areas</a>. </p>
<p>Rural areas have their own problems with the program. Their residents are poorer and more likely to be on Medicaid. The prevalence of Medicaid coverage, and its stingier reimbursements, is one reason why hospitals in rural areas <a href="http://kff.org/report-section/a-look-at-rural-hospital-closures-and-implications-for-access-to-care-three-case-studies-issue-brief/">have closed down</a>. </p>
<p>In theory, federal matching funds are designed to shore up the Medicaid budgets of poorer states. California, for instance, has a 50 percent match rate – tied for lowest in the country – while Mississippi has a 75.6 percent match rate, the <a href="http://kff.org/medicaid/state-indicator/federal-matching-rate-and-multiplier/">highest in the country</a>.</p>
<p>But in practice, federal matching funds do not go far enough. As an example, each disabled Medicaid beneficiary in Mississippi receives <a href="http://kff.org/medicaid/state-indicator/medicaid-spending-per-enrollee/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">about half as much in benefits as their peers in Maryland.</a> Mississippi ranks as the poorest state in the nation according to <a href="https://www.justice.gov/ust/eo/bapcpa/20140401/bci_data/median_income_table.htm">median household income</a> (for four-person households), while Maryland ranks as the richest. To make matters worse, the AHCA proposes to reduce federal matching funds below their current, already inadequate levels. </p>
<p>State control of Medicaid was designed to foster experimentation and competition among states to provide efficient, high-quality care for the poor. And, the AHCA relies heavily on the logic that Medicaid will run better when states have greater financial responsibility and control. </p>
<p>However, rising inequality between rich and poor areas of the country has undercut this rationale. As poorer states fall farther behind, they become ever less capable of mustering the resources needed to protect the growing ranks of vulnerable children, adults and seniors among their constituents. </p>
<p>From this standpoint, further cuts to Medicaid – as envisioned by the AHCA – make little sense. Why make an underfunded program even more underfunded? Replacing Medicaid with an adequately funded alternative would make more sense than retaining the program and rendering it even less capable of aid to the poor.</p>
<h2>The paradox of Medicaid expansions</h2>
<p>The Affordable Care Act expanded Medicaid coverage to <a href="https://www.cbo.gov/sites/default/files/recurringdata/51298-2017-01-healthinsurance.pdf">more than 20 million additional Americans</a> by providing financial assistance and incentives to states that extended Medicaid eligibility – up to annual incomes of $16,643 for an individual or $33,948 for a family of four. But even so, it has not done enough over the long term to increase the number of health care providers willing to care for Medicaid patients. </p>
<p>Research suggests that higher Medicaid reimbursements would lead <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2444286">more physicians to accept Medicaid</a>. And, in 2013 and 2014, the ACA increased Medicaid reimbursements, <a href="https://www.ncbi.nlm.nih.gov/pubmed/27355810">resulting in greater access to care</a>. </p>
<p>Unfortunately, the ACA’s increase in reimbursements were only temporary. Payments to providers went back down to pre-2013 levels in 2015. The result has been longer wait times and <a href="https://www.ncbi.nlm.nih.gov/pubmed/28273021">greater difficulty in accessing care among Medicaid beneficiaries.</a> </p>
<p>At the same time, the most compelling evidence suggests the <a href="https://scholar.harvard.edu/files/hendren/files/finkelstein_hendren_luttmer_mcaid_welfare_june_16_2015.pdf">government spends more on Medicaid than the value it provides to the poor</a>. For every dollar the government spends on Medicaid, the poor get roughly 20 to 40 cents of value. Much of the benefits accrue to third parties such as hospitals and employers who, in the absence of Medicaid, <a href="https://scholar.harvard.edu/files/hendren/files/finkelstein_hendren_luttmer_mcaid_welfare_june_16_2015.pdf">would have provided uncompensated medical care</a> to Medicaid’s beneficiaries.</p>
<h2>Democrats should demand providers be paid more – but only for value</h2>
<p>Let’s start with the Democrats. Saving Medicaid coverage may well be a worthy goal. But expanding Medicaid by expanding the number of Medicaid beneficiaries does the poor a disservice if it doesn’t provide greater access for them to doctors. Medicaid expansions should also come with higher payments to providers. </p>
<p>But if Medicaid pays physicians more, it should require that they deliver more value. Specifically, physicians who achieve better outcomes should be reimbursed more than those achieving worse outcomes. The institutional details of such “<a href="http://healthaffairs.org/blog/2017/04/03/strategies-to-address-the-challenges-of-outcomes-based-pricing-agreements-for-pharmaceuticals/">outcomes-based pricing</a>” deserve their own careful discussion, but we think <a href="https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Value-Based-Programs.html">pay-for-performance reforms</a> are consistent with core Democratic principles of fairness and protection of the vulnerable. </p>
<p>How could the Democrats pay for their desired expansions in both coverage and generosity? Getting rid of the highly regressive tax break for employer-sponsored health insurance would be a good start, especially for a party looking to level the playing field between the rich and the poor. </p>
<p>The tax code allows people to buy health insurance before they pay taxes. This lowers their taxable income. The value of this tax deduction increases with your tax rate – the higher your tax rate, the greater the value of reducing your taxable income. <a href="http://www.taxpolicycenter.org/briefing-book/how-does-tax-exclusion-employer-sponsored-health-insurance-work">This deduction costs the government over $250 billion in tax revenue each year</a>. Eliminating it and earmarking the revenue for Medicaid would help the poor and reduce inequality. </p>
<h2>Republicans should encourage competition among insurers</h2>
<p>And what about the Republicans? Expanding government-administered insurance programs does not comport with Republican values of competition and free choice. Yet, cutting government programs without providing a meaningful market-based alternative does not make sense, either.</p>
<p>For guidance, Republicans should look to the last major health care reform by a Republican administration: Medicare Part D, a prescription drug benefit for the elderly. Unlike the main physician and hospital care benefits in Medicare, Part D was set up as a system of government subsidies for the purchase of private prescription drug insurance. </p>
<p>By most measures, Part D has been a success – <a href="https://www.cbo.gov/sites/default/files/113th-congress-2013-2014/reports/45552-PartD.pdf">cost growth has been less than originally projected</a> by the Congressional Budget Office and <a href="https://www.ncbi.nlm.nih.gov/pubmed/28273626">it lowered deaths among the elderly by 2.2 percent annually</a>. </p>
<p>Republicans who oppose Medicaid should consider replacing it with a properly funded system of subsidies for private health insurance. Such a plan would take the savings from phasing out the current Medicaid system and invest it into more generous subsidies for the purchase of private health insurance. This approach would provide mainstream health care coverage to Medicaid enrollees. Integrating the poor into the middle class and above is a core Republican value, and this reform would provide an opportunity to advance that agenda.</p>
<h2>Moving forward</h2>
<p>The debate over the AHCA promises to intensify, as American politicians have now splintered into more than two camps. The rising number of factions makes compromise essential, as no single bloc of senators can push through legislation unaided.</p>
<p>We believe the best path forward starts with all sides putting their best ideas forward. This means the best ideas for government-administered health insurance on the left, and the best ideas for market-based health insurance on the right. All of these ideas should aim toward securing the health of the most vulnerable American children and families. Perhaps that is the one principle we all can agree on.</p><img src="https://counter.theconversation.com/content/75524/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Darius Lakdawalla is the Chief Scientific Officer of Precision Health Economics (PHE), where he also serves as the Executive Director of PHE's Innovation and Value Initiative. He is an investor in PHE's parent company, Precision Medicine Group. PHE conducts research for pharmaceutical, biotechnology, medical device, and health insurance firms. The article reflects the views of its authors and not those of PHE or Precision Medicine Group.</span></em></p><p class="fine-print"><em><span>Anup Malani consulted for Precision Health Economics in 2016 on the topic of rebates for HIV/AIDs drug purchases.</span></em></p><p class="fine-print"><em><span>Jay Bhattacharya is a senior researcher at Acumen, LLC, which provides economic consulting services for the Center for Medicare and Medicaid Services (CMS) which administer both Medicare and Medicaid programs for the federal government. Dr. Bhattacharya has also received grant funding from the National Institute on Aging to study issues related to healthcare access for the poor and other vulnerable populations. The article reflects his own opinions, and not those of CMS, the NIH, or Acumen LLC.</span></em></p>The health care bill recently passed by the House imposes big cuts to the underfunded Medicaid program. A new approach is needed, starting with the best ideas of both parties.Darius Lakdawalla, Professor of Pharmaceutical Development and Regulatory Innovation, Schaeffer Center for Health Policy and Economics, University of Southern CaliforniaAnup Malani, The Lee and Brena Freeman Professor at the University of Chicago Law School and Professor at the Pritzker School of Medicine., University of ChicagoJay Bhattacharya, Professor of Medicine, Stanford UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/771382017-05-05T01:26:24Z2017-05-05T01:26:24ZHow pre-existing conditions became front and center in health care vote<figure><img src="https://images.theconversation.com/files/167948/original/file-20170504-21616-1iddpd7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Rep. Billy Long (R-Mo.) speaks to reporters outside the White House on May 3, 2017 after a meeting with the president on proposed legislation that could limit coverage for preexisting conditions. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/Search?query=fred+upton&ss=10&st=es&entitysearch=P%7CFred+Upton%7CCEE638D367D54A209FC2FB0F2BE2311C&toItem=15&orderBy=Newest&searchMediaType=excludecollections">Susan Walsh/AP</a></span></figcaption></figure><p>Pre-existing conditions became the focus of debate on the American Health Care Act, which was narrowly passed 217-213 by the House of Representatives.</p>
<p>The debate led to bitter disagreement, as Republicans sought to undo a requirement of the Affordable Care Act that insurers be forced to cover pre-existing conditions and at the same premiums as others.</p>
<p>The issue, long contentious, gained further fuel this week through two illustrative videos seen by millions of Americans. On the one hand, a tearful late-night show host <a href="http://time.com/money/4763061/jimmy-kimmel-baby-obamacare/">Jimmy Kimmel</a> described the nightmare of every parent when his son was born with a serious, complex, and costly birth defect. On the other hand, <a href="https://www.commondreams.org/news/2017/05/02/exposing-gop-cruelty-alabama-rep-says-pre-existing-conditions-are-your-fault">Rep. Mo Brooks</a> (R-AL) stated that those Americans “who lead good lives” and have “done the things to keep their bodies healthy” should not have to support Americans with pre-existing conditions.</p>
<p>Why should this be such a contentious issue? As someone who <a href="http://simonfhaeder.wixsite.com/home/academic">studies and teaches</a> health care policy in West Virginia, one of the states with the <a href="http://kff.org/health-reform/issue-brief/pre-existing-conditions-and-medical-underwriting-in-the-individual-insurance-market-prior-to-the-aca/">highest percentage</a> of individuals with pre-existing conditions, let me offer some answers. </p>
<h2>What is a pre-existing condition, anyway?</h2>
<p>Pre-existing conditions are health conditions which were diagnosed or treated by a provider prior to the purchase of insurance. <a href="http://www.ilhealthagents.com/bluecross-blueshield-illinois/pre-existing-condition-exclusions/">Twenty-three states</a> even include cases where individuals did not seek medical attention but when a “prudent” person would have sought care. </p>
<p>Pre-existing conditions apply only to those circumstances where the sale of insurance policies is based on individual risk, as opposed to risk spread across many people, such as in employer-sponsored insurance or Medicare. </p>
<p>Addressing the contentious issue of pre-existing conditions, and most importantly how to distribute the costs associated with them, is a crucial one for all health care systems. The issue has been with us from the very emergence of health insurance, particularly as for-profit insurers sought to minimize their risks and to maximize their profits.</p>
<p>However, while most other industrialized nations have long resolved the issue equitably, the U.S. continues to struggle with it, even after the passage of the ACA. </p>
<p>Before passage of the ACA, pre-existing conditions were subject to a confusing mix of state and federal laws, regulations and enforcement. <a href="http://kff.org/other/state-indicator/individual-market-portability-rules/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Elimination%20Riders%20Permitted%22,%22sort%22:%22desc%22%7D">Almost 20 percent of the states provided</a> no definition of preexisting conditions at all. </p>
<p>Insurers hence had significant leeway in determining what counted as a preexisting condition unless a state <a href="http://www.nytimes.com/2008/06/01/health/01insure.html">specifically banned the practice for certain conditions</a>.</p>
<p>States also differed on how far back health conditions were relevant, ranging from <a href="http://www.ilhealthagents.com/bluecross-blueshield-illinois/pre-existing-condition-exclusions/">six months to indefinitely</a>.</p>
<p>Insurers could elect to deny coverage altogether to individuals with preexisting conditions in most states. In others, insurers charged much higher premiums for those with preexisting conditions.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/167952/original/file-20170504-21616-1lv7f6q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/167952/original/file-20170504-21616-1lv7f6q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/167952/original/file-20170504-21616-1lv7f6q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/167952/original/file-20170504-21616-1lv7f6q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/167952/original/file-20170504-21616-1lv7f6q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/167952/original/file-20170504-21616-1lv7f6q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/167952/original/file-20170504-21616-1lv7f6q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Man being treated for sleep apnea, once an excluded preexisting condition.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/539015356?src=9x1Jlo3FOwbjYR5gUcj9Ew-1-3&size=huge_jpg">From www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>Insurers are generally not concerned about preexisting conditions per se, but only about those that are expected to incur significant medical costs in the future. </p>
<p>Basing their decisions on risk models, individual insurers have developed lists of <a href="http://files.kff.org/attachment/Issue-Brief-Pre-existing-Conditions-and-Medical-Underwriting-in-the-Individual-Insurance-Market-Prior-to-the-ACA">declinable conditions</a> (such as substance abuse, acne and sleep apnea), <a href="http://files.kff.org/attachment/Issue-Brief-Pre-existing-Conditions-and-Medical-Underwriting-in-the-Individual-Insurance-Market-Prior-to-the-ACA">medications</a> (such as heparin, Zyrexa and Interferon) or <a href="http://files.kff.org/attachment/Issue-Brief-Pre-existing-Conditions-and-Medical-Underwriting-in-the-Individual-Insurance-Market-Prior-to-the-ACA">occupations</a> (such as miners, pilots and air traffic controllers).</p>
<p>A congressional report found that <a href="http://thehill.com/images/stories/blogs/memo1.pdf">425 medical diagnoses</a> have been used to decline coverage. </p>
<p>Certain reasons for rejection fueled public outrage more than others. For example, immediately prior to the ACA’s passage, being the victim of domestic violence counted as a preexisting condition <a href="http://www.mcclatchydc.com/news/politics-government/article24557818.html">in eight states</a>. </p>
<p>Similarly, many insurers also included <a href="http://www.huffingtonpost.com/2009/10/21/insurance-companies-rape-_n_328708.html">rape</a> as a pre-existing condition, and <a href="https://www.healthinsurance.org/blog/2012/04/28/health-reform-a-huge-victory-for-women/2/">45 states</a> allowed the practice for C-sections.</p>
<h2>How the idea of denying coverage got started</h2>
<p>The issue of pre-existing conditions is not new to the American health care system. At the beginning – in the 1920s and 1930s – emerging health insurers like Blue Cross and Blue Shield were created as nonprofits with special tax treatment. Most plans charged the same rates to all consumers.</p>
<p>As the insurance market became more profitable, for-profit insurers entered the market. Focused on maximizing their profits, these companies sought to attract only the healthiest individuals. They did this by offering lower premiums than their nonprofit competitors to healthy individuals. </p>
<p>Naturally, this entailed excluding individuals with preexisting conditions. In order to avoid being left with only the sickest individuals, all insurers eventually had to move to medical underwriting, at least in the individual market.</p>
<p>Over time, both states and federal government enacted certain, albeit very limited, protections, such as high-risk pools, for individuals with preexisting conditions. </p>
<p>Some states also required insurers to issue policies to all comers. These <a href="http://kff.org/other/state-indicator/individual-market-guaranteed-issue-not-applicable-to-hipaa-eligible-individuals/?currentTimeframe=0&sortModel=%7B%22colId%22%3A%22Location%22%2C%22sort%22%3A%22asc%22%7D">guaranteed issue requirements,</a> however, often did not address costs issues. </p>
<p>As result, while consumers may not have been denied coverage, they were penalized with higher premiums for having these conditions. </p>
<p>Common efforts to limit losses for insurers from those with preexisting conditions included the temporary or permanent <a href="http://kff.org/other/state-indicator/individual-market-portability-rules/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Elimination%20Riders%20Permitted%22,%22sort%22:%22desc%22%7D">restriction of benefits for certain enrollees</a> based on their health condition; the creation of so-called <a href="https://www.ehealthinsurance.com/short-term-health-insurance">bare-bone plans</a> or allowing insurers to charge <a href="http://www.nytimes.com/2008/06/01/health/01insure.html">discriminatory premiums</a>. </p>
<p>However, none of the approaches offered a comprehensive solution.</p>
<p>A study by the <a href="https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwiH0vvAyNTTAhUERCYKHQQFCbsQFggnMAA&url=http%3A%2F%2Fwww.commonwealthfund.org%2F%7E%2Fmedia%2FFiles%2FPublications%2FIssue%2520Brief%2F2009%2FJul%2FFailure%2520t">Commonwealth Fund in 2007</a> found that 36 percent of individuals had been turned down or charged a higher price for a preexisting condition.</p>
<p>An <a href="http://thehill.com/images/stories/blogs/memo1.pdf">investigation by the Committee on Energy and Commerce</a> of the House of Representatives showed that the nation’s four largest for-profit insurers covering close to three million individuals had turned down more than 600,000 individuals between 2007 and 2009. Moreover, during the same period they refused to pay medical treatment for a preexisting condition for more than 200,000 claims.</p>
<p>Those most closely affected were those 16 million Americans (in 2008) who held policies in the individual market and the additional <a href="http://khn.org/news/census-number-of-uninsured-drops/">50 million</a> who were uninsured.</p>
<p>However, transition between insurance is inherently frequent in a <a href="http://www.commonwealthfund.org/publications/blog/2017/mar/premium-surcharge-under-aca-repeal-bill">mobile society</a> like the United States. A significant number of people in any given year lose their jobs. Both instances leave many Americans uncovered for at least part of the year, and potentially seeking insurance in the individual market.</p>
<h2>Obamacare’s call for coverage</h2>
<p>The pre-existing condition issue is one pretty much unique to the American health system.</p>
<p>The ACA sought to solve the issue through a variety of arrangements surrounding the <a href="http://onlinelibrary.wiley.com/doi/10.1111/puar.12065/full">insurance marketplaces</a> including community rating, a minimum amount of benefits (the <a href="https://theconversation.com/essential-health-benefits-suddenly-at-center-of-health-care-debate-but-what-are-they-75125">Essential Health Benefits</a>), the elimination of annual and lifetime benefit limits, and subsidies. </p>
<p>In contrast, the American Health Care Act would allow insurers to charge higher premiums to those individuals. </p>
<p>The AHCA does offer some very limited funding to offset its negative effects. However, policy experts, providers and patient groups have described these as <a href="https://www.forbes.com/sites/brucejapsen/2017/04/27/doctors-hospitals-say-latest-trumpcare-version-a-bigger-disaster/#31e786c91ea4">inadequate</a>. The most recent <a href="http://www.politico.com/story/2017/05/02/health-care-republicans-obamacare-237910">Upton Amendment</a> slightly increased this funding – something that possibly contributed to the law’s passage. But policy experts continue to see the funding as significantly <a href="https://www.vox.com/policy-and-politics/2017/5/3/15538556/republican-health-care-bill-ahca-upton-amendment">too small</a>.</p>
<h2>Are we all in this together, or not?</h2>
<p>Millions of Americans could potentially be affected by the changes under the new legislation. </p>
<p>The point is that pre-existing conditions remain ubiquitous in American society. A <a href="http://kff.org/health-reform/issue-brief/pre-existing-conditions-and-medical-underwriting-in-the-individual-insurance-market-prior-to-the-aca/">Kaiser Family Foundation analysis</a> a few months ago found 52 million Americans under age 65, or 27 percent of the population would not be able to obtain insurance on their own under pre-ACA conditions. </p>
<p>The situation was considerably worse in states like West Virginia, Mississippi, Kentucky and Alabama, where more than one in three residents, according to the analysis, would not be able to.</p>
<p>Making sure that those among us with pre-existing conditions have health care is challenging and unquestionably costly. It also requires a degree of sacrifice, in terms of higher premiums, from those who, at any given point in time, are relatively healthy.</p>
<p>What is required is a degree of solidarity with our neighbors, friends and family members who, often through no fault of their own, have suffered from poor health. Not the least, it is a degree of solidarity with our own future selves as all of us could fall sick at any point in time.</p>
<p>Americans of all political persuasions seem to be willing to make the required sacrifices. Most Americans, including 63 percent of Republicans and 75 percent of Democrats in a <a href="http://kff.org/slideshow/us-public-opinion-on-health-care-reform-2017/">recent poll</a>, support the preexisting condition components of the Affordable Care Act.</p><img src="https://counter.theconversation.com/content/77138/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>How preexisting conditions came to be a condition for passage of the Republicans’ health care law is a complicated tale. Insurers created the cost-saving technique, excluding millions over the years.Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/772152017-05-04T20:34:49Z2017-05-04T20:34:49ZHow did health insurance get so complicated? Here are some answers<figure><img src="https://images.theconversation.com/files/167974/original/file-20170504-5995-1l56ddi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Two swing votes: Rep. Fred Upton (R-Mich.) and Rep. Greg Waldon (R-Ore.), after striking a deal with Pres. Trump on the heath care bill. </span> <span class="attribution"><span class="source">Susan Walsh/AP Photo</span></span></figcaption></figure><p>With the passage of the Republicans’ health care act, the House of Representatives seems to be saying that coming up with a plan to insure Americans really wasn’t all that hard after all. It just took a bit more of a subsidy – US$8 billion to be precise – for really sick people to make Congress comfortable with the alternative to the Affordable Care Act. </p>
<p>But from being a professor of health finance and a former insurance CEO, I know that it is really much more difficult than this to keep all the insurers competing aggressively in the market, all the providers focused on high quality and all the patients choosing wisely among their options for coverage and care.</p>
<p>One of the biggest underlying problems is confusion over what we are buying here and what incentives are necessary to get everyone to behave.</p>
<h2>What are we buying anyway?</h2>
<p>The first confusion is over the very nature of health insurance. The discussion often reveals an assumption that we are just buying a service and paying for it much as we finance a new car. So why should I pay more in financing costs than I actually get? If I want a VW, why should I pay for a BMW? I don’t need maternity services or mental health, but they are part of the standard package of essential benefits that I have to buy. And this drives up my premium.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/167980/original/file-20170504-21620-1bay2zz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/167980/original/file-20170504-21620-1bay2zz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/167980/original/file-20170504-21620-1bay2zz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/167980/original/file-20170504-21620-1bay2zz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/167980/original/file-20170504-21620-1bay2zz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/167980/original/file-20170504-21620-1bay2zz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/167980/original/file-20170504-21620-1bay2zz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Want a BMW?</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/kiev-ukraine-14-may-2014-bmw-379233436">Sabuhi Novruzov/www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>But health insurance is not car financing. By its very nature, it is the strangest of products, one that I hope I will not have to use but is there when I need it. I am not buying specific services but access to potential services, the particulars of which are unknowable in advance. This ticket to ride is very valuable, but pricing it is devilishly difficult.</p>
<p>To make this work, I have to share my potential need with a large group of like-minded consumers who also hope they won’t have to use the ticket. But unlike the lottery, where I want to win and get all that money for the $2 ticket I bought, I am unhappy if I “win” with my health insurance and get back more than I paid when I have a serious illness. It is this confusing nature of the product that leads to bad policy and bad purchasing decisions.</p>
<h2>Proposed patch will wear thin</h2>
<p>The <a href="http://www.businessinsider.com/ahca-high-risk-pools-healthcare-vote-obamacare-2017-5">patch</a> proposed by the AHCA is to pull out of the insurance pool more of those who are likely to need services, leaving the rest with a premium that is closer to what they actually are likely to need on a one-to-one basis. </p>
<p>Loosening up the requirements on pricing to let insurers charge more for people with varying conditions moves us even closer to this image. Why shouldn’t the sick pay more since they use more services? The apparent hope is to come closer to the implicit assumption of health care as car financing – I get what I pay for.</p>
<p>Unfortunately for all of us, this is a losing proposition. There will always be more at the margin who would qualify for coverage under the high-risk pools, driving the cost of these beyond any arbitrary funding, be it $8 billion or $800 billion. </p>
<p>Our experience in many states in the past is that these pools are <a href="http://kff.org/health-reform/issue-brief/high-risk-pools-for-uninsurable-individuals/">inevitably underfunded</a>, leaving those who would qualify the butt of a cruel joke – they can’t get conventional health insurance, but the cost of even the high-risk pool is excessive due to underfunding. </p>
<p>This is the real concern over high-risk pools as an alternative to offering coverage to all, regardless of pre-existing conditions. While economists suggest that this <a href="http://thehealthcareblog.com/blog/2012/03/07/what-is-the-cause-of-excess-costs-in-us-health-care-take-two/">excess demand </a>is the patient’s fault (the so-called “moral hazard” of excess demand when something is covered), no one chooses to have a heart condition, diabetes or a birth defect.</p>
<h2>Payment shapes decisions and incentives</h2>
<p>Another problem comes from, again, the misconception of health insurance as the financing of a known product. Besides just paying for services when needed, we also want to create incentives for prevention and high quality and lowest cost settings to provide them when they are needed. </p>
<p>The Affordable Care Act has moved health care far down this path through <a href="http://www.modernhealthcare.com/article/20161111/MAGAZINE/161109907">value-based payment</a>, which rewards providers for higher quality and lower total cost over the whole spectrum of care, not just for a single service.</p>
<p>But while providers have received the message loud and clear and reacted with <a href="http://www.modernhealthcare.com/article/20161111/MAGAZINE/161109907">major advances</a> on quality and cost, we have far to go in creating similar incentives for the patient. This is where the “skin in the game” argument, as a way to make individuals more responsible for their own care, has some credibility. </p>
<p>But AHCA supporters went further. Under their replacement bill, it is OK to penalize people for being sick, even if it is not their “fault,” and regardless of their wealth or income. </p>
<p>The new legislation’s <a href="http://www.businessinsider.com/biggest-drop-in-subsidies-for-cities-under-ahca-trumpcare-2017-3">subsidies depend on age</a>, not income, and entirely remove the cost-sharing reductions that make high-deductible plans on the Obamacare exchanges feasible for the working poor just above the poverty level. </p>
<p>With these changes, clearly health insurance is no longer affordable for those who were the main target of the ACA.</p>
<p>Admittedly, premiums for those other than the near poor are higher under the ACA, even if health care inflation in general has been largely tamed. Those who support the lower-premium, stripped-down plans of the AHCA replacement bill focus on the concerns of those who now must buy more expensive policies that cover everything they might need – but without the subsidies the poor receive. </p>
<p>So if I think I can predict what I will need and want a plan that will finance this like my new car, then I probably don’t need insurance at all. </p>
<p>And, if I do want coverage and can afford to pay for it, the replacement legislation will do just fine. Because I have the money, I can buy a BMW policy, if I choose.</p>
<p>However, if I am poor – or if I care about a stable insurance market – this is a jalopy with recycled tires, a torn leather seat and an engine about to blow.</p><img src="https://counter.theconversation.com/content/77215/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>J.B. Silvers is on the board of MetroHealth Medical Center</span></em></p>Even Pres. Trump said he had no idea that health insurance can be so complicated.
Part of the reason is that it’s not something we really want to buy – and not something we want to buy for others.J.B. Silvers, Professor of Health Finance, Case Western Reserve UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/747392017-04-04T00:45:08Z2017-04-04T00:45:08ZHow Ayn Rand’s ‘elitism’ lives on in the Trump administration<figure><img src="https://images.theconversation.com/files/163680/original/image-20170403-21966-1htznjn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/perspective/481293482/in/photolist-JwKMu-87NNJY-5ToRGh-d2Km-dYfsLP-9i65p1-awi32Z-33n1-qDJMhf-cQr1zL-cRKrr3-9udLYw-9uanSc-fJNyMY-4f5ndt-ej2RKo-6kxddV-6wZ2cQ-bX3PQ6-cRJUtJ-9TFPqQ-dVCDt8-cz2LHq-4MxMwY-6cL529-5ZAUwn-v8k1A-SdLY8z-52JCH5-ej2XW3-5ghwDp-5ghcTv-ej2BWA-cTWSxy-eiVUHP-fvEQjw-eaB6Uy-fvEPX1-eiW2NT-4zxmoy-ej2Rro-7rZRD-5ghJBR-7bAZzJ-5gmxoE-5gnfiY-5gmzBo-JQ9ww-bBkuwZ-2mHuTc">Elvert Barnes</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>Trump’s secretary of state, Rex Tillerson, has <a href="https://www.washingtonpost.com/news/powerpost/paloma/daily-202/2016/12/13/daily-202-ayn-rand-acolyte-donald-trump-stacks-his-cabinet-with-fellow-objectivists/584f5cdfe9b69b36fcfeaf3b/?utm_term=.7bc706cd74aa">said</a> Ayn Rand’s novel “Atlas Shrugged” is his favorite book. Mike Pompeo, head of the CIA, <a href="https://www.washingtonpost.com/news/powerpost/paloma/daily-202/2016/12/13/daily-202-ayn-rand-acolyte-donald-trump-stacks-his-cabinet-with-fellow-objectivists/584f5cdfe9b69b36fcfeaf3b/?utm_term=.7bc706cd74aa">cited</a> Rand as a major inspiration. Before he withdrew his nomination, Trump’s pick to head the Labor Department, Andrew Puzder, <a href="https://www.washingtonpost.com/news/powerpost/paloma/daily-202/2016/12/13/daily-202-ayn-rand-acolyte-donald-trump-stacks-his-cabinet-with-fellow-objectivists/584f5cdfe9b69b36fcfeaf3b/?utm_term=.7bc706cd74aa">revealed</a> that he devotes much free time to reading Rand.</p>
<p>Such is the case with many other Trump advisers and allies: The Republican leader of the House of Representatives, Paul Ryan, famously <a href="http://nymag.com/daily/intelligencer/2014/07/7-ways-paul-ryan-revealed-his-love-for-ayn-rand.html">made</a> his staff members read Ayn Rand. Trump himself has said that <a href="https://www.washingtonpost.com/news/powerpost/paloma/daily-202/2016/12/13/daily-202-ayn-rand-acolyte-donald-trump-stacks-his-cabinet-with-fellow-objectivists/584f5cdfe9b69b36fcfeaf3b/?utm_term=.2c86b5d9fc9e">he’s a “fan” of Rand</a> and “identifies” with Howard Roark, the protagonist of Rand’s novel, “The Fountainhead,” “an architect who dynamites a housing project he designed because the builders did not precisely follow his blueprints.”</p>
<p>As a philosopher, I have often wondered at the remarkable endurance and popularity of Ayn Rand’s influence on American politics. Even by earlier standards, however, Rand’s dominance over the current administration looks especially strong.</p>
<h2>What’s in common with Ayn Rand?</h2>
<p>Recently, historian and Rand expert <a href="https://history.stanford.edu/people/jennifer-burns">Jennifer Burns</a> wrote how Rand’s sway over the Republican Party is <a href="https://www.washingtonpost.com/posteverything/wp/2017/03/03/ayn-rand-is-dead-liberals-are-going-to-miss-her/?utm_term=.3753ff7d205c">diminishing</a>. Burns says the promises of government largesse and economic nationalism under Trump would repel Rand. </p>
<p>That was before the president unveiled his proposed federal budget that <a href="http://www.chicagotribune.com/news/nationworld/politics/ct-trump-budget-20170315-story.html">greatly slashes</a> nonmilitary government spending – and before Paul Ryan’s Obamacare reform, which promised to <a href="https://www.theguardian.com/us-news/2017/mar/13/budget-office-republican-healthcare-coverage-deficit-costs">strip health coverage</a> from 24 million low-income Americans and grant the rich a generous tax cut instead. Now, Trump looks to be zeroing in on a significant tax cut for the rich and corporations. </p>
<p>These all sound like measures Rand would enthusiastically support, in so far as they assist the capitalists and so-called job creators, instead of the poor. </p>
<p>Though the Trump administration looks quite steeped in Rand’s thought, there is one curious discrepancy. Ayn Rand exudes a robust elitism, unlike any I have observed elsewhere in the tomes of political philosophy. But this runs counter to the narrative of the Trump phenomenon: <a href="http://www.nationalreview.com/corner/445255/thoughts-about-spinning-our-president">Central</a> to the Trump’s ascendancy is a rejection of elites reigning from urban centers and the coasts, overrepresented at universities and in Hollywood, apparently.</p>
<p>Liberals despair over the fact that they are branded elitists, while, as former television host Jon Stewart <a href="http://www.rawstory.com/2016/07/jon-stewart-shreds-gop-hypocrites-who-overlook-trumps-flaws-i-see-you-and-i-see-your-bullsht/">put</a> it, Republicans backed a man who takes every chance to tout his superiority, and lords over creation from a gilded penthouse apartment, in a skyscraper that bears his own name.</p>
<p>Clearly, liberals lost this rhetorical battle.</p>
<h2>What is Ayn Rand’s philosophy?</h2>
<p>How shall we make sense of the gross elitism at the heart of the Trump administration, embodied in its devotion to Ayn Rand – elitism that its supporters overlook or ignore, and happily ascribe to the left instead?</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/163685/original/image-20170403-21976-1a3qgo1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/163685/original/image-20170403-21976-1a3qgo1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=470&fit=crop&dpr=1 600w, https://images.theconversation.com/files/163685/original/image-20170403-21976-1a3qgo1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=470&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/163685/original/image-20170403-21976-1a3qgo1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=470&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/163685/original/image-20170403-21976-1a3qgo1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=590&fit=crop&dpr=1 754w, https://images.theconversation.com/files/163685/original/image-20170403-21976-1a3qgo1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=590&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/163685/original/image-20170403-21976-1a3qgo1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=590&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In this 1962 file photo Ayn Rand, Russian-born American novelist, is photographed in New York with Grand Central Terminal in the background.</span>
<span class="attribution"><span class="source">AP Photo</span></span>
</figcaption>
</figure>
<p>Ayn Rand’s philosophy is quite straightforward. Rand sees the world divided into “makers” and “takers.” But, in her view, the real makers are a select few – a real elite, on whom we would do well to rely, and for whom we should clear the way, by reducing or removing taxes and government regulations, among other things.</p>
<p>Rand’s thought is intellectually digestible, unnuanced, easily translated into policy approaches and statements.</p>
<p>Small government is in order because it lets the great people soar to great heights, and they will drag the rest with them. Rand <a href="https://books.google.com/books?id=eWZbq29waP8C&pg=PT23&lpg=PT23&dq=the+exceptional+men,+the+innovators,+the+intellectual+giants,+are+not+held+down+by+the+majority.+In+fact,+it+is+the+members+of+this+exceptional+minority+who+lift+the+whole+of+a+fre">says</a> we must ensure that “the exceptional men, the innovators, the intellectual giants, are not held down by the majority. In fact, it is the members of this exceptional minority who lift the whole of a free society to the level of their own achievements, while rising further and ever further.”</p>
<p>Mitt Romney <a href="https://www.washingtonpost.com/news/the-fix/wp/2013/03/04/why-mitt-romneys-47-percent-comment-was-so-bad/?utm_term=.feb0071af4be">captured</a> Rand’s philosophy well during the 2012 campaign when he spoke of the 47 percent of Americans who do not work, vote Democrat and are happy to be supported by hardworking, conservative Americans.</p>
<h2>No sympathy for the poor</h2>
<p>In laying out her dualistic vision of society, divided into good and evil, Rand’s language is often starker and harsher. In her 1957 novel, “Atlas Shrugged,” she <a href="https://books.google.com/books?id=bVyCd7da8OcC&printsec=frontcover&dq=atlas+shrugged&hl=en&sa=X&ved=0ahUKEwi-j46L6O_SAhUIbiYKHaNtBkAQ6AEIHDAA#v=onepage&q=brains&f=false">says</a>, </p>
<blockquote>
<p>“The man at the top of the intellectual pyramid contributes the most to all those below him, but gets nothing except his material payment, receiving no intellectual bonus from others to add to the value of his time. The man at the bottom who, left to himself, would starve in his hopeless ineptitude, contributes nothing to those above him, but receives the bonus of all their brains.”</p>
</blockquote>
<p>Rand’s is the opposite of a charitable view of humankind, and can, in fact, be quite cruel. Consider her attack on Pope Paul VI, who, in his 1967 encyclical <a href="http://w2.vatican.va/content/paul-vi/en/encyclicals/documents/hf_p-vi_enc_26031967_populorum.html">Progressio Populorum</a>, argued that the West has a duty to help developing nations, and called for its sympathy for the global poor.</p>
<p>Rand was appalled; instead of feeling sympathy for the poor, she <a href="http://en.liberpedia.org/Requiem_for_Man">says</a> </p>
<blockquote>
<p>“When [Western Man] discovered entire populations rotting alive in such conditions [in the developing world], is he not to acknowledge, with a burning stab of pride – or pride and gratitude – the achievements of his nation and his culture, of the men who created them and left him a nobler heritage to carry forward?”</p>
</blockquote>
<h2>Telling it like it is</h2>
<p>Why doesn’t Rand’s elitism turn off Republican voters? – or turn them against their leaders who, apparently, ought to disdain lower and middle class folk? If anyone – like Trump – identifies with Rand’s protagonists, they must think themselves truly excellent, while the muddling masses, they are beyond hope. </p>
<p>Why hasn’t news of this disdain then trickled down to the voters yet?</p>
<p>The neoconservatives, who held sway under President George W. Bush, were also quite elitist, but figured out how to speak to the Republican base, in their language. Bush himself, despite his Andover-Yale upbringing, was <a href="http://usatoday30.usatoday.com/news/opinion/columnist/benedetto/2004-09-17-benedetto_x.htm">lauded</a> as “someone you could have a beer with.”</p>
<p>Trump has succeeded even better in this respect – he famously “tells it like it is,” his supporters like to <a href="http://www.huffingtonpost.com/halim-shebaya/trump-tells-it-like-it-is_b_9836974.html">say</a>. Of course, as judged by fact-checkers, Trump’s relationship to the truth is embattled and tenuous; what his supporters seem to appreciate, rather, is his willingness to voice their suspicions and prejudices without worrying about recriminations of critics. Trump says things people are reluctant or shy to voice loudly – if at all.</p>
<h2>Building one’s fortune</h2>
<p>This gets us closer to what’s going on. Rand is decidedly cynical about the said masses: There is little point in preaching to them; they won’t change or improve, at least of their own accord; nor will they offer assistance to the capitalists. The masses just need to stay out of the way. </p>
<p>The principal virtue of a free market, Rand <a href="https://books.google.com/books?id=bVyCd7da8OcC&printsec=frontcover&dq=atlas+shrugged&hl=en&sa=X&ved=0ahUKEwi-j46L6O_SAhUIbiYKHaNtBkAQ6AEIHDAA#v=onepage&q=brains&f=false">explains</a>, is “that the exceptional men, the innovators, the intellectual giants, are not held down by the majority. In fact, it is the members of this exceptional minority who lift the whole of a free society to the level of their own achievements…” </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/163677/original/image-20170403-21960-ll8pim.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/163677/original/image-20170403-21960-ll8pim.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/163677/original/image-20170403-21960-ll8pim.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/163677/original/image-20170403-21960-ll8pim.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/163677/original/image-20170403-21960-ll8pim.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/163677/original/image-20170403-21960-ll8pim.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/163677/original/image-20170403-21960-ll8pim.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Ayn Rand opposed welfare for the poor.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/rationalthought/3447039194/in/photolist-6fAYEf-2LHfox-q2pXTF-gjjhVJ-bWWqA2-nRiJhR-5mVuLy-5XzZGN-nNgues-9uc559-9hctvL-vEQuL-7XApuC-cmAR6m-auGb3Q-aw56pr-9u8hac-q1RAFX-5VoL8M-9uauU6-7NfTkX-dX6zSh-8kjZ2o-87pbGm-6GjTr5-iGKia-fn4ft-6tn5y1-9u9Djg-5gn7jS-9hC4Li-6uZdMo-azhFHE-7AZbBp-dhh6C5-dfrMXk-aE7n5T-2n1eo-99TH2K-gZkBS-9amayy-5xdaz6-W2J7F-4pezyh-dhfTxr-qXDjr8-8FL8C3-rU6n6h-7vWBwJ-qnWmD">Kevin Copps</a>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>But they don’t lift the masses willingly or easily, she <a href="https://books.google.com/books?id=bVyCd7da8OcC&printsec=frontcover&dq=atlas+shrugged&hl=en&sa=X&ved=0ahUKEwi-j46L6O_SAhUIbiYKHaNtBkAQ6AEIHDAA#v=onepage&q=brains&f=false">says</a>: “While the majority have barely assimilated the value of the automobile, the creative minority introduces the airplane. The majority learn by demonstration, the minority are free to demonstrate.”</p>
<p>Like Rand, her followers – who populate the Trump administration – are largely indifferent to the progress of the masses. They will let people be. Rand believes, quite simply, most people are hapless on their own, and we simply cannot expect much of them. There are only a few on whom we should pin our hopes; the rest are simply irrelevant. Which is why she <a href="https://books.google.com/books?id=eWZbq29waP8C&pg=PT56&lpg=PT56&dq=while+those+who+produce+and+provided+it+had+not+The+welfare+and+rights+of+the+producers+were+not+regarded+as+worthy+of+consideration+or+recognition.+This+is+the+most+damning+indictment+of+the+present+state+of+our+culture&source=bl&ots=NSWzyE6H5d&sig=TsH0VITbSHkdNfJHeBnflN0_bBY&hl=en&sa=X&ved=0ahUKEwij2PXcyoHTAhXD5CYKHXxSBWoQ6AEIHDAA#v=onepage&q=damning&f=false">complains</a> about our tendency to give welfare to the needy. She says,</p>
<blockquote>
<p>“The welfare and rights of the producers were not regarded as worthy of consideration or recognition. This is the most damning indictment of the present state of our culture.”</p>
</blockquote>
<p>So, why do Republicans get away with eluding the title of elitist – despite their allegiance to Rand – while Democrats are stuck with this title?</p>
<p>I think part of the reason is that Democrats, among other things, are moralistic.
They are more <a href="https://www.theguardian.com/commentisfree/2010/nov/20/human-nature-politics-left-right">optimistic</a> about human nature – they are more optimistic about the capacity of humans to progress morally and live in harmony.</p>
<p>Thus, liberals judge: They call out our racism, our sexism, our xenophobia. They make people <a href="http://www.americanthinker.com/articles/2017/01/political_correctness_as_a_tool_of_the_liberal_inquisition.html">feel bad</a> for harboring such prejudices, wittingly or not, and they warn us away from potentially offensive language, and phrases.</p>
<p>Many conservative opponents scorn liberals for their ill-founded naïve optimism. For in Rand’s world there is no hope for the vast majority of mankind. She <a href="http://en.liberpedia.org/Requiem_for_Man">heaps scorn</a> on the poor billions, whom “civilized men” are prodded to help.</p>
<p>The best they can hope for is that they might be lucky enough to enjoy the riches produced by the real innovators, which might eventually trickle down to them in their misery. </p>
<p>To the extent that Trump and his colleagues embrace Rand’s thought, they must share or approach some of her cynicism.</p><img src="https://counter.theconversation.com/content/74739/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Firmin DeBrabander does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Despite promises to rural working class, a philosopher argues, the Republican Party is still under the influence of the elitism of novelist Ayn Rand.Firmin DeBrabander, Professor of Philosophy, Maryland Institute College of ArtLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/751842017-03-28T02:39:52Z2017-03-28T02:39:52ZDid medical Darwinism doom the GOP health plan?<figure><img src="https://images.theconversation.com/files/162548/original/image-20170327-18980-dl97nf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">House Speaker Paul Ryan announced March 24 that he was pulling his proposed health care bill from consideration. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Health-Overhaul-Tax-Reform/2a6d4f6c9dec4b91ba6d57ef76165814/1/0">Scott Applewhite/AP</a></span></figcaption></figure><p><em>“We are now contemplating, Heaven save the mark, <a href="https://archive.org/stream/newyorkstatejour4919medi#page/1904/mode/2up/search/Heaven+save+the+mark">a bill that would tax the well for the benefit of the ill</a>.”</em> </p>
<p>Although that quote reads like it could be part of the Republican repeal-and-replace assault against the Affordable Care Act (ACA), it’s actually from a 1949 editorial in The New York State Journal of Medicine denouncing health insurance itself.</p>
<p>Indeed, the attacks on the ACA seem to have revived a survival-of-the-fittest attitude most of us thought had vanished in America long ago. Yet, again and again, there it was in plain sight, as when House Speaker Paul Ryan (R-WI) <a href="https://www.theatlantic.com/health/archive/2017/03/the-biggest-criticism-of-paul-ryans-health-care-pitch/519138/">declared</a>: “The idea of Obamacare is that the people who are healthy <a href="http://wgxa.tv/news/connect-to-congress/watch-house-speaker-paul-ryans-powerpoint-presentation-on-gop-health-care-bill">pay for the people who are sick</a>.” Contemporary language, but the same thinking that sank President <a href="http://www.pbs.org/newshour/updates/november-19-1945-harry-truman-calls-national-health-insurance-program/">Harry Truman’s health care plan</a> almost seven decades ago.</p>
<p>Ryan’s indignation highlighted a fundamental divergence in attitudes that repeatedly turned the health care debate into a clash over the philosophy behind Obamacare-style health insurance. To some, the communal pooling of financial risk of medical expenses seems too often an unacceptable risk to personal responsibility. </p>
<p>As a researcher who has <a href="http://press.uchicago.edu/Misc/Chicago/525872.html">documented</a> this approach to health care, I’ve been startled to see the debate over the AHCA reignite a political philosophy and policy approach that seemed to be have been discredited – and be in sharp decline.</p>
<p>When Truman launched the <a href="http://www.pbs.org/newshour/updates/november-19-1945-harry-truman-calls-national-health-insurance-program/">first comprehensive effort</a> to cover all Americans, most of the population had no health insurance. </p>
<p>Last year, thanks to the ACA, nearly 90 percent did, according to a Gallup-Healthways <a href="http://www.gallup.com/poll/201641/uninsured-rate-holds-low-fourth-quarter.aspx">poll</a>. Yet then and now, many conservatives have downplayed the impact on physical health and focused, instead, on fiscal temptation. </p>
<h2>If you can’t afford to be sick, then don’t be</h2>
<p>Take, for instance, Rep. Jason Chaffetz (R-UT) <a href="http://www.politico.com/story/2017/03/jason-chaffetz-new-gop-health-care-plan-235762">warning low-income Americans</a> on March 7, 2017 that they had “to make a choice” about their spending: “So rather than getting that new iPhone that they just love and want to go spend hundreds of dollars on that, maybe they should invest in their own health care.” (He <a href="http://www.cnn.com/2017/03/07/politics/jason-chaffetz-health-care-iphones/">later walked back</a> his statement.) </p>
<p>In reality, of course, the premiums from the GOP’s late and abandoned American Health Care Act would dwarf any savings from iPhone abstinence. For a 64-year-old making US$26,500 a year, the cost of health insurance would have shot up from $1,700 to $14,600, <a href="http://time.com/money/4700402/republican-obamacare-replacement-cbo-numbers/">according to the Congressional Budget Office</a> (CBO), or more than half that individual’s pre-tax income.</p>
<p>Chaffetz and others seem to sincerely believe that “what keeps the great majority of people well is the fact that they can’t afford to be ill” – although those words come from the 1949 editorialist again, not a Trump administration tweet. The editorial continued:</p>
<p><em>That is a harsh, stern dictum and we readily admit that under it a certain number of cases of early tuberculosis and cancer, for example, may go undetected. Is it not better that a few such should perish rather than that the majority of the population should be encouraged on every occasion to run sniveling to the doctor? That in order to get their money’s worth they should be sick at every available opportunity? They will find out in time that the services they think they get for nothing – but which the whole people of the United States would pay for – are also worth nothing.</em></p>
<p>As it happens, the effect predicted in 1949 on the detection of cancer – less of it – is precisely what has happened with the spread of high-deductible health plans praised by conservatives for encouraging more careful “shopping” by “consumers.” A <a href="https://www.ncbi.nlm.nih.gov/pubmed/27078821">study</a> in Medical Care showed that screening rates for colorectal cancer declined under high-deductible plans until, under Obamacare, the federal government forced those plans to include first-dollar coverage of preventive services. The screening rates for colorectal cancer promptly rose. A recent <a href="http://onlinelibrary.wiley.com/doi/10.1002/cncr.30476/full">study</a> in Cancer found the same results for mammography.</p>
<p>Separately, <a href="http://healthaffairs.org/blog/2015/10/07/trouble-ahead-for-high-deductible-health-plans/">surveys and research</a> on high-deductible plans have found that 20 to 25 percent of people have avoided needed care of all kinds because they can’t afford it.</p>
<p>Nonetheless, the GOP’s conservative wing denounced ACA-mandated “<a href="https://theconversation.com/essential-health-benefits-suddenly-at-center-of-health-care-debate-but-what-are-they-75125">essential health benefits</a>,” echoing the idea that it is a <a href="http://talkingpointsmemo.com/news/boehner-health-care-greatest-threat-to-freedom-i-ve-seen-in-last-19-years">threat to American freedom</a>. Or as that same <a href="https://archive.org/stream/newyorkstatejour4919medi#page/2130/mode/2up/search/darwin">New York medical journal</a> put it:</p>
<p><em>It is time that someone – everyone – should hoist Mr. Charles Darwin from his grave and blow life into his ashes so that they could proclaim again to the world his tough but practical doctrine of survival of the fittest…The Declaration of Independence said that man was entitled to the “pursuit of happiness.” Any man who wishes to pursue happiness had better be able to stand on his own feet. He will not be successful if he feels that he can afford to be ill</em>.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/162555/original/image-20170327-18984-4cwik4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/162555/original/image-20170327-18984-4cwik4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=851&fit=crop&dpr=1 600w, https://images.theconversation.com/files/162555/original/image-20170327-18984-4cwik4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=851&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/162555/original/image-20170327-18984-4cwik4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=851&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/162555/original/image-20170327-18984-4cwik4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1069&fit=crop&dpr=1 754w, https://images.theconversation.com/files/162555/original/image-20170327-18984-4cwik4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1069&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/162555/original/image-20170327-18984-4cwik4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1069&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Charles Darwin.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/charles-darwin-18091882-circa-1870s1980s-252138244?src=ySZVMopUaF3zX0ZFp8CsGQ-1-1">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<h2>The quality of mercy is not strained</h2>
<p>For most physicians, that compassionless condescension lies in the faraway past; for example, the AHCA was overwhelmingly opposed by medical professional groups, including the <a href="https://www.nytimes.com/2017/03/08/health/american-medical-association-opposes-republican-health-plan.html">American Medical Association</a>. </p>
<p>Yet an implacable medical Darwinism retains a firm grip on many conservatives, even on physicians. Then-Oklahoma Sen. Tom Coburn, an obstetrician/gynecologist and prominent Republican, <a href="https://newrepublic.com/article/68779/who-my-neighbor">told a sobbing woman</a> at a 2009 public meeting on the ACA that “government is not the answer” when she said she couldn’t afford care for her brain-injured husband. </p>
<p>Similarly, in 2011, after the ACA passed, then-Rep. Ron Paul (R-TX), also an obstetrician/gynecologist, <a href="http://abcnews.go.com/blogs/politics/2011/09/tea-party-debate-audience-cheered-idea-of-letting-uninsured-patients-die/">was asked what should be done</a> about an uninsured, 30-year-old man in a coma. “What he should do is whatever he wants to do and <a href="http://www.npr.org/sections/thetwo-way/2011/09/13/140434378/ron-paul-its-not-governments-job-to-take-care-of-uninsured">assume responsibility for himself</a>,” Paul responded, adding, “That’s what freedom is all about, taking your own risk.”</p>
<p>Or as conservative scholar Michael Strain <a href="https://www.washingtonpost.com/opinions/end-obamacare-and-people-could-die-thats-okay/2015/01/23/f436df30-a1c4-11e4-903f-9f2faf7cd9fe_story.html?utm_term=.63f80e225e31">put it</a> in a 2015 Washington Post editorial: “In a world of scarce resources, a slightly higher mortality rate is an acceptable price to pay for certain goals – including…less government coercion and more individual liberty.”</p>
<p>Strain is right, of course, that resources are limited. Moreover, <a href="http://www.journals.uchicago.edu/doi/abs/10.1086/260027">it’s long been known</a> that overgenerous health insurance can lead to overuse of medical care services. </p>
<p>However, most Americans, including some <a href="https://www.forbes.com/sites/theapothecary/2017/03/11/how-paul-ryans-obamacare-replacement-would-trap-millions-in-poverty-and-how-to-fix-it/#1668572c4168">prominent conservative intellectuals</a>, don’t see stripping away health insurance from 24 million countrymen – the CBO’s estimate of the AHCA’s 10-year impact – as striking a blow for liberty. In a <a href="https://poll.qu.edu/national/release-detail?ReleaseID=2443">Quinnipiac University poll</a> released just before the scheduled AHCA vote, only 17 percent of respondents approved of the Republican plan and 46 percent said they’d be less likely to vote for someone who supported it.</p>
<p>One day later, GOP leaders withdrew the legislation, sparing Republican representatives a vote “on the record.” Although Vice President Mike Pence has <a href="http://www.inquisitr.com/3706347/trump-vp-mike-pence-dismisses-evolution-believes-darwin-only-had-a-theory/">called evolution an unproven theory</a>, it turns out Republicans really do believe in “survival of the fittest” (at least in a political sense), after all.</p><img src="https://counter.theconversation.com/content/75184/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael L. Millenson does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The U.S. has been arguing about health care for decades. Critics have argued that insurance for all is a sign of weakness or even Communist. Here’s a look at how the thinking has evolved – or not.Michael L. Millenson, Adjunct Associate Professor of Medicine, Feinberg School of Medicine, Northwestern UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/751702017-03-24T23:24:02Z2017-03-24T23:24:02ZRepublicans fumble ACA repeal: Expert reaction<p><em>Editor’s note: The fight didn’t last long. Moments before a scheduled vote on March 24, House Speaker Paul Ryan pulled the bill that would have repealed the Affordable Care Act. It was a surprisingly swift defeat for a legislative priority talked up by Republicans since the day Obamacare first passed. We asked congressional scholars what the retreat means – and what comes next.</em></p>
<h2>Trump legislative agenda now in serious doubt</h2>
<p><strong>Richard A. Arenberg, Brown University</strong></p>
<p>President Trump and the Republican congressional leadership have suffered a stunning defeat. The inability of the new president and his GOP majority to pass the American Health Care Act in the House places in question their ability to accomplish their central campaign promise of repealing Obamacare. It also creates significant obstacles for the remainder of the Trump legislative agenda, especially the planned tax cut. </p>
<p>The conflicting demands by factions in the health care debate have laid bare huge fissures in the Republican caucus – fissures which had been masked by apparent unity in the wake of Trump’s surprising election. Further, the failure of this first test of the Trump administration and its allies on the Hill raises serious questions about Speaker Ryan’s ability to bridge those gaps.</p>
<p>The bill, pulled by the speaker before it could suffer defeat on the House floor, <a href="https://www.cbo.gov/sites/default/files/115th-congress-2017-2018/costestimate/americanhealthcareact.pdf">contained more than US$880 billion of tax reductions</a> over 10 years. </p>
<p>GOP leaders have been counting on that reduction to the revenue base to permit a large tax reform bill to be passed using the reconciliation process. Reconciliation would permit the tax bill to be passed in the Senate with a simple majority, foreclosing the possibility of a Democratic filibuster. </p>
<p>However, in order to qualify under Senate rules, that bill must be revenue-neutral. The plan to use the tax reductions contained in the American Health Care Act was one of the main reasons that the Republican congressional leadership convinced Trump to undertake the health care bill first.</p>
<p>The wisdom of that strategy will come under severe scrutiny in the White House in the days ahead.</p>
<h2>Will the GOP ever get its act together?</h2>
<p><strong>Christopher Sebastian Parker, University of Washington</strong></p>
<p>By now, the GOP should should be tired of this: public implosion. </p>
<p>Ever since the Tea Party showed up on the scene in 2009, the Republican Party slips on every banana peel in sight. The fight between the party’s moderate wing and the more reactionary one led former Senate Minority Leader Bob Dole (R-KS) to say that neither he nor president Ronald Reagan <a href="http://www.csmonitor.com/USA/Politics/DC-Decoder/2013/0526/Bob-Dole-says-Reagan-couldn-t-make-it-in-today-s-GOP.-Is-he-right">could get elected in today’s GOP</a>. </p>
<p>This was followed by the ouster of former House Majority Leader Eric Cantor (R-VA), who was primaried by Tea Party candidate Dave Brat in 2014. Why? He was perceived as <a href="https://www.washingtonpost.com/local/virginia-politics/eric-cantor-faces-tea-party-challenge-tuesday/2014/06/10/17da5d20-f092-11e3-bf76-447a5df6411f_story.html?utm_term=.1b021c8d9e2a">too moderate</a>. He was the first sitting majority leader to lose since 1899. </p>
<p>This was followed by the GOP resignation of Speaker John Boehner (R-OH) in 2015 because, he, too, was perceived to be <a href="https://www.nytimes.com/2015/09/26/us/john-boehner-to-resign-from-congress.html">too moderate</a>.</p>
<p>Now this. The Freedom Caucus is responsible for the current public rift in the GOP. What’s that old saying? “Be careful what you wish for.” Well, the GOP got its wish to govern, and they’re blowing it.</p><img src="https://counter.theconversation.com/content/75170/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard Arenberg is a member of the Board of Directors of Social Security Works. </span></em></p><p class="fine-print"><em><span>Christopher Sebastian Parker does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Trump cuts bait, Ryan loses his nerve – and the Obamacare repeal goes down without a vote. What’s next for Congress and the GOP?Richard A. Arenberg, Visiting Lecturer in Political Science and International and Public Policy, Brown UniversityChristopher Sebastian Parker, Professor of Political Science, University of WashingtonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/751252017-03-24T20:02:48Z2017-03-24T20:02:48ZEssential health benefits suddenly at center of health care debate, but what are they?<figure><img src="https://images.theconversation.com/files/162385/original/image-20170324-12149-cq5bed.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Lisa Schwetschenau, who has multiple sclerosis, shown in a photo in Omaha, Nebraska on March 16. She worries that she could lose some of her essential health benefits under the new proposed health care law.</span> <span class="attribution"><span class="source">Nati Harnik/AP</span></span></figcaption></figure><p>Republicans have <a href="http://www.cnbc.com/2017/03/22/heres-why-the-gop-is-coming-up-short-on-votes-to-repeal-obamacare.html">tirelessly campaigned</a> to repeal and replace the <a href="https://www.medicaid.gov/affordable-care-act">Affordable Care Act (ACA)</a> with a conservative, market-based approach to health care. Almost seven years after its passage, and with the election of a Republican president and Congress, the ACA appeared destined to be repealed and potentially replaced. </p>
<p>The House was scheduled to but did not vote on March 24 on that replacement, the <a href="http://www.speaker.gov/HealthCare">American Health Care Act (AHCA)</a>. In the debate running up to the vote, a major sticking point was a relatively obscure, albeit important, component of the ACA called the <a href="https://www.healthcare.gov/coverage/what-marketplace-plans-cover/">Essential Health Benefit (EHB)</a> provision. </p>
<p>These benefits are those deemed “essential” by the authors of the ACA. They include maternity and newborn care, prescription drugs, emergency services and hospitalization. </p>
<p>As a public policy professor, I have studied the EHB provision, their benefits and drawbacks, and how they fit into the overarching construct of the ACA. While there may be room to improve the EHB provision, I have no doubt that outright eliminating the essential health benefits provisions of the ACA would prove to be disastrous.</p>
<h2>How the benefits came to be - and to be so loathed</h2>
<p>The provision has, together with the individual mandate, long been a bane to conservatives and libertarians. Opponents of the ACA see the EHB as restricting consumer choice and artificially inflating the cost of insurance. </p>
<p>Nonetheless, the elimination of the EHB was initially not included in the Republican efforts to repeal the ACA. Indeed, it was added only when it became clear that the Republican leadership lacked the votes to pass the AHCA because of the <a href="https://www.washingtonpost.com/news/powerpost/wp/2017/03/22/what-the-freedom-caucus-wants-in-the-gop-health-bill-and-why-they-arent-getting-it/?utm_term=.5fb1e06af28f">recalcitrance of their most conservative members</a>. </p>
<p>Prior to the ACA, it was up to each respective state to determine what benefits, called insurance mandates, had to be included in insurance plans. Not surprisingly, states differed widely in terms comprehensiveness required, and no specific benefit was deemed essential in all 50 states and Washington, D.C.</p>
<p>While most states required the <a href="https://lintvwpri.files.wordpress.com/2013/10/mandatesinthestates2011execsumm.pdf">inclusion of such benefits</a> as emergency room services (44 states), far fewer required coverage for well-child visits (32), contraceptives (30), maternity services (25), rehabilitation services (7) or prescription drugs (5).</p>
<h2>Pre-ACA requirements were weak</h2>
<p>Even when essential services requirements were in place before the ACA, they were often fairly weak and allowed insurers to make coverage optional or to cap allowable benefits. This greatly affected what and how much care people had access to. </p>
<p>For example, 62 percent of individuals in the individual market lacked maternity coverage and <a href="https://aspe.hhs.gov/basic-report/essential-health-benefits-individual-market-coverage">34 percent lacked coverage for substance abuse disorder treatment</a>.</p>
<p>Thus, the EHB provisions were included in the ACA, for many reasons. First, the <a href="https://www.medicaid.gov/affordable-care-act">ACA was intended</a> to provide coverage that offers viable protection against some of the most basic health care costs Americans experience. </p>
<p>Also, EHBs were designed to provide marketplace consumers with insurance coverage similar to the coverage of employer-sponsored insurance and Medicaid. It would not be a pared-back, bare-bones policy commonly available prior to the ACA.</p>
<p>Another goal was to empower consumers by helping them to compare different insurance plans in the insurance marketplaces. As all plans are required to provide the same basic services, insurers would be required to compete on a level playing field – and not by artificially reducing premiums by excluding essential services. </p>
<p>However, the inclusion of a minimum set of benefits also had technical reasons that are soundly based in health economics. As insurers are now required to accept all interested consumers, insurers with a more comprehensive benefit design would inevitably attract a disproportionate number of sick, and thus costly, individuals. Health economists refer to this process as <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1541-0072.2012.00446.x/abstract">adverse selection</a>. As a result, premiums for these insurers would significantly increase. In response, insurers could either adjust their benefit design or exit the market.</p>
<p>Finally, the broad set of benefits was meant to attract a large, diverse pool of consumers who would jointly share risk and cost for the services covered under the EHB. By attracting a diverse set on consumers, insurers would not be disproportionately exposed to certain high-cost individuals and the overall insurance market would be stabilized. </p>
<p>By requiring insurers to compete on price and quality – and by not allowing them to utilize benefit design to discourage individuals to sign up for their plans – sicker individuals are more evenly spread among all insurers. </p>
<h2>What would happen without them?</h2>
<p>ACA opponents have argued these requirements restrict consumer choice and artificially inflate the cost of insurance. However, eliminating the EHB provisions would likely entail a variety of negative consequences for individual consumers, insurance market, and the broader health care system. </p>
<p>The difficulty for consumers to understand and navigate the health care and insurance system is <a href="http://content.healthaffairs.org/content/22/4/147.full">well-documented</a>. The EHB guarantee consumers that a <a href="http://www.sciencedirect.com/science/article/pii/S0168851014002607">certain set of basic services</a> are included in their insurance and that they are covered in case of sickness. Without EHBs, insurance plans with different benefit designs and structures would likely proliferate. The amount of information would likely overwhelm most consumers and thus make the comparison of insurance plans virtually impossible. </p>
<p>More generally, the elimination of the EHB requirement could dramatically impact insurance markets across the country. No longer required to provide a certain minimum of benefits, insurers <a href="https://www.nytimes.com/2017/03/23/upshot/late-gop-proposal-could-mean-plans-that-cover-aromatherapy-but-not-chemotherapy.html?_r=0">would successively reduce benefits</a> (a race to the skimpiest plan, if you will) in order to attract only the healthiest consumers. These people are the least likely to use services and thus prefer plans with limited protections and lower premiums. Eventually, most if not all plans would be <a href="https://www.nytimes.com/2017/03/23/upshot/late-gop-proposal-could-mean-plans-that-cover-aromatherapy-but-not-chemotherapy.html?_r=0">priced at the available tax credits</a> offered under the AHCA, because at that point these plans would essentially be free for eligible Americans.</p>
<p>As insurers move toward offering ever skimpier plans, individuals would remain free to purchase additional benefits. However, insurers could charge prohibitively high prices for these optional benefits. Or, they could be hesitant to offer these optional benefits at all, as only individuals who expect to use them would be likely to purchase them. </p>
<p>Similarly, healthy individuals could sign up for the skimpiest available insurance plans in order to fulfill the requirement to remain continuously insured. They would then expand their benefits without incurring a penalty in case they fall sick and have large health costs to cover. Or, as the AHCA premium penalties are set rather low, the healthiest individuals could completely defer obtaining such coverage until a major medical need is incurred. Again, insurers would anticipate this behavior and refuse to offer comprehensive coverage.</p>
<p>Ultimately, eliminating the EHB essentially individualizes risk and cost by shrinking the risk pool down to a single individual, a situation similar to the situation prior to the enactment of the ACA. However, health insurance works best by creating a large, diverse pool of consumers with varying health care costs. The ACA sought to achieve this goal by combining the EHB with requirements for insurers to accept all consumers and for consumers to obtain coverage or pay a fine. If people sign up only when they are sick, it raises costs and makes plans unsustainable for insurers. </p>
<h2>A need to reevaluate, not eliminate</h2>
<p>This situation would potentially be further exacerbated by Republican plans to allow for the <a href="http://khn.org/news/sounds-like-a-good-idea-selling-insurance-across-state-lines/">selling of insurance across state lines</a>. Even if liberal states like California were to maintain similar consumer protections as present in the ACA, it is conceivable, even likely, that more conservative states like Florida would quickly move in the opposite direction. That is, they would allow for the sale of so-called bare-bones plans with few benefits or catastrophic plans – plans that only offer protection in case of significant financial exposure. </p>
<p>Both types of plans would naturally be less expensive compared to the more comprehensive plans, and thus attract the healthiest individuals. This has the potential of triggering a death spiral in the insurance markets of more protective states as their premiums would would skyrocket. </p>
<p>As such, individual consumers would bear significant hardship due to the elimination of the EHB. More limited coverage will inevitably lead to higher out-of-pocket costs for consumers.</p>
<p>The negative effects would likely be compounded for the broader health care system. Hospitals will be subject to increasing uncompensated care costs and will then shift these costs either to other consumers or be forced to close their doors. Also, a lot of the benefits of prevention and early intervention would likely be lost.</p>
<p>The EHBs have undeniably <a href="http://www.heritage.org/health-care-reform/report/obamacare-and-insurance-benefit-mandates-raising-premiums-and-reducing">raised insurance premiums</a>. However, this is hardly surprising because they have done so by reducing out-of-pocket costs and by providing consumers with <a href="https://www.nytimes.com/2016/04/21/upshot/obamacare-seems-to-be-reducing-peoples-medical-debt.html">meaningful protection against the vagaries of sickness</a>. </p>
<p><a href="http://www.sciencedirect.com/science/article/pii/S0168851014002607">In my own work</a>, I have shown the diverse approaches that states have taken to adapt the EHB to their local health insurance markets. Unfortunately, <a href="http://gradworks.umi.com/10/16/10164660.html">I have also shown</a> that states often do not rely on available policy expertise to balance adequate coverage with affordability. </p>
<p>Considering the benefits of EHBs, it would be prudent for all stakeholders to continuously revisit the important question of what services should be included in the EHB and which ones should not.</p><img src="https://counter.theconversation.com/content/75125/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Essential health benefits under Obamacare are suddenly the center of controversy in the proposed replacement bill. If certain health benefits are so essential, why are they so loathed? Here’s a look.Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/743982017-03-12T19:13:47Z2017-03-12T19:13:47ZThe House health plan: Here’s how the numbers don’t add up for the poor<figure><img src="https://images.theconversation.com/files/160366/original/image-20170310-19247-138a875.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Melva Watt, right, senior Medicaid interviewer, assists a patient with her application for Medicaid through the New York State Marketplace.
</span> <span class="attribution"><span class="source">Julie Jacobson/AP</span></span></figcaption></figure><p>House Republicans <a href="http://healthaffairs.org/blog/2017/03/07/examining-the-house-republican-aca-repeal-and-replace-legislation/">introduced the American Health Care Act</a> (AHCA), their proposal to repeal and replace the Affordable Care Act (ACA, also known as Obamacare). </p>
<p>At a press conference, Speaker Paul Ryan called this bill “<a href="http://www.usatoday.com/videos/news/nation/2017/03/07/paul-ryan-health-care-reform-'act-mercy'/98878852/">an act of mercy</a>.” For the most vulnerable, that characterization is ironic at best.</p>
<p>Yes, there are winners in this bill. But those who benefit would be predominantly young, healthy and less likely to need insurance or older, well off and more likely to be able to afford insurance. </p>
<p>The potential effects of this bill on certain segments of the population are clear: For the <a href="https://www.cdc.gov/pcd/issues/2014/13_0389.htm">millions of Americans with multiple chronic conditions</a>, and for <a href="https://www.ssa.gov/cgi-bin/netcomp.cgi?year=2015">nearly 100 million Americans</a> who earn less than US$40,000 a year, AHCA would bring less coverage and higher costs than under the ACA.</p>
<h2>A quick review</h2>
<p>First, it’s important to understand how much the ACA has helped Americans afford health insurance coverage. In 2009, <a href="https://factfinder.census.gov/bkmk/table/1.0/en/ACS/09_1YR/S2701">15.1 percent</a> of Americans were uninsured. By 2015, that number had fallen to <a href="https://factfinder.census.gov/bkmk/table/1.0/en/ACS/15_1YR/S2701">9.4 percent</a>. </p>
<p>Those who gained coverage did so primarily through the expansion of Medicaid and through the ACA’s health insurance marketplace. These coverage expansions have provided crucial assistance to low-income Americans, many of whom were unable to afford coverage before the ACA.</p>
<p>Today, adults with incomes up to 138 percent of the federal poverty level, or about $16,394 in 2017, are eligible to enroll in Medicaid in the 32 states, including the District of Columbia, that expanded the program. </p>
<p>The law had originally intended for all states to expand their Medicaid programs; a 2012 Supreme Court ruling made the expansion a state option. People with incomes up to 400 percent of the federal poverty level, or $47,520 in 2017, can get financial assistance to purchase coverage on the Health Insurance Marketplace.</p>
<p>In 2016, nearly <a href="https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-06-30.html">9.4 million people</a> – 85 percent of Health Insurance Marketplace enrollees – received tax credits to help pay for premiums. </p>
<p>In addition, under the ACA, individuals with incomes less than 250 percent of the federal poverty level, or $29,700 in 2017, receive cost-sharing reduction subsidies to help pay for copays and deductibles. </p>
<p>Almost <a href="https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-06-30.html">6.4 million people</a> – 57 percent of 2016 Health Insurance Marketplace enrollees – received these subsidies to help lower their out-of-pocket costs. The cost-sharing subsidies helped people to afford health care as well as insurance coverage.</p>
<h2>Presidential promises for insurance for everyone – and cheaper</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/160369/original/image-20170310-19226-n9e4uh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/160369/original/image-20170310-19226-n9e4uh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/160369/original/image-20170310-19226-n9e4uh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/160369/original/image-20170310-19226-n9e4uh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/160369/original/image-20170310-19226-n9e4uh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/160369/original/image-20170310-19226-n9e4uh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/160369/original/image-20170310-19226-n9e4uh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">President Donald Trump speaks in the Roosevelt Room of the White House in Washington, Friday, March 10, 2017, during a meeting on health care.</span>
<span class="attribution"><span class="source">Evan Vucci/AP</span></span>
</figcaption>
</figure>
<p>Over the past several months, President Trump has <a href="https://www.washingtonpost.com/politics/trump-vows-insurance-for-everybody-in-obamacare-replacement-plan/2017/01/15/5f2b1e18-db5d-11e6-ad42-f3375f271c9c_story.html?tid=ss_tw&utm_term=.65c62a393e38">promised</a> an ACA replacement plan that will provide “insurance for everybody” that is “much less expensive and much better” with “much lower deductibles.” </p>
<p>Those promises are good benchmarks to help us evaluate the impact of the American Health Care Act. </p>
<p>In its current form, the AHCA simply does not accomplish any of those goals for people with low incomes, people over 60, or people who live in areas where health care costs are high, such as rural areas. Indeed, the AHCA may end up putting health coverage out of reach for many of those who gained it under the ACA.</p>
<p>The AHCA replaces the ACA’s income-based premium tax credits with age-adjusted tax credits (with an income limit of $115,000). Under the AHCA, adults in their 20’s would receive a $2,000 annual tax credit to help purchase individual market coverage, with tax credits increasing up to $4,000 for a 60-year-old. </p>
<p>These proposed tax credits <a href="http://healthaffairs.org/blog/2017/03/07/examining-the-house-republican-aca-repeal-and-replace-legislation/">do not take into account</a> an individual’s income or the price of health insurance in their area, as the ACA did. According to the <a href="http://kff.org/health-reform/issue-brief/how-affordable-care-act-repeal-and-replace-plans-might-shift-health-insurance-tax-credits/">Kaiser Family Foundation</a>, the average annual premium tax credit in 2017 under the ACA for a 60-year-old making $20,000 a year was $9,874.</p>
<p>Under the AHCA, that same 60-year-old would receive <a href="http://kff.org/health-reform/issue-brief/how-affordable-care-act-repeal-and-replace-plans-might-shift-health-insurance-tax-credits/">less than half</a> that amount, according to an analysis by the Kaiser Family Foundation. In many areas of the United States, particularly rural areas, older Americans would receive <a href="https://www.nytimes.com/interactive/2017/03/08/upshot/who-wins-and-who-loses-under-republicans-health-care-plan.html">significantly less financial assistance</a> to help pay for premiums than they currently receive.</p>
<p>Under the ACA, the premium tax credit amount that enrollees may receive is based on two key factors: the local benchmark premium cost and the enrollee’s household income. Under the AHCA, premium tax credits would be based only on age and would not be tailored to local costs.
The AHCA would also repeal the ACA’s cost-sharing subsidies in 2020, putting care even further out of reach for many.</p>
<p>The AHCA would expand those age bands so that older adults could now be charged up to five times higher premiums than their younger counterparts. Older adults could not only see a decrease in financial assistance to pay for premiums, but their premiums could increase as well.</p>
<h2>More to the problem than Medicaid loss</h2>
<p>For the <a href="http://www.modernhealthcare.com/article/20161109/NEWS/161109895">12 million people</a> who are now covered through Medicaid expansion, the outlook is equally gloomy. The AHCA would freeze Medicaid expansion beginning in 2020. States that had already expanded the program would continue to receive enhanced federal funding for current enrollees who remain on the program. </p>
<p>But states would receive far less federal funding to cover any new enrollees or any existing enrollee who experiences a lapse in coverage longer than one month. Many states would find it difficult to continue Medicaid expansion under these circumstances.</p>
<p>In addition, beginning in 2020, the bill would shift Medicaid to a per-capita cap. This would be a fundamental restructuring of the Medicaid program, affecting over <a href="http://kff.org/health-reform/state-indicator/total-monthly-medicaid-and-chip-enrollment/?currentTimeframe=0&selectedRows=%7B%22wrapups%22:%7B%22united-states%22:%7B%7D%7D%7D">70 million people</a>. </p>
<p>Unlike today, where the federal government guarantees it will match states’ costs to provide care to Medicaid beneficiaries, a per-capita cap would give states a fixed amount of money per enrollee. The state would be responsible for any expenses beyond that amount. </p>
<p>According to the <a href="http://www.cbpp.org/medicaid-cost-shifts-in-house-gop-plan-would-total-an-estimated-370-billion-over-10-years-and-grow">Center for Budget and Policy Priorities</a>, the AHCA’s proposed Medicaid changes would shift $370 billion in costs to states over 10 years. As a result, states would try to contain costs by curtailing benefits or limiting enrollment in their Medicaid programs – not just in the expansion population, but across the board. </p>
<p>While House Republicans claim these changes will grant more flexibility to states to make innovations in their Medicaid programs, the proposed structure would likely end up cutting benefits for millions of adults and children as states scramble to fill the shortfall from fewer federal Medicaid dollars.</p>
<p>Perhaps the AHCA can improve coverage and lower costs, but the real question is: For whom? </p>
<p>For the young, healthy, and high-income earners, quite possibly. But for lower-income individuals, older adults, people living in rural areas and people who gained Medicaid coverage under the ACA, it seems unlikely that the AHCA is anything but a bad deal.</p><img src="https://counter.theconversation.com/content/74398/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Megan Foster Friedman does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>House Speaker Paul Ryan called the new health care proposal an ‘act of mercy.’ The bill could help the healthy and wealthy, but it is unlikely to be merciful to the poor.Megan Foster Friedman, Health Policy Analyst, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/545332016-04-05T09:50:02Z2016-04-05T09:50:02ZWhen covering elections, journalists face a debilitating dilemma<p>Last week, President Obama <a href="http://www.nytimes.com/2016/03/29/us/obama-urges-journalists-to-cover-the-substance-of-the-campaign.html">criticized journalists covering the election</a> for “the practice of drawing ‘false equivalences’ between competing claims made by politicians.” </p>
<p>“If I say the world is round and someone else says it’s flat, that’s worth reporting,” he <a href="http://www.nytimes.com/2016/03/29/us/obama-urges-journalists-to-cover-the-substance-of-the-campaign.html">said</a>. “But you might also want to report on a bunch of scientific evidence that seems to support the notion that the world is round.”</p>
<p>Unfortunately, it is not so simple. </p>
<p>In an ongoing research project, I have been using game theory to study how, in the right circumstances, a political party can make excessive demands in negotiations, lie brazenly, or otherwise behave in unusual and problematic ways. They’re often able to do this because journalists today are ill-equipped to stop it or bring attention to it.</p>
<p>While I don’t have a solution, I can at least point out a culprit: partisan media outlets, which put objective journalists in an impossible bind that <a href="http://artscidirectory.case.edu/wp-content/uploads/2013/07/journalistsdilemma.pdf">I call</a> “the journalist’s dilemma.” </p>
<p>Unless they want to be accused of bias, journalists must pretend that the objective truth is always the precise midpoint between the Democrats’ and Republicans’ positions based on the premise that the parties are equally extreme, equally dishonest, and equally guilty of all other political sins. </p>
<p>But to quote “<a href="https://www.youtube.com/watch?v=kP5O_NUhrK0">Porgy and Bess</a>,” it ain’t necessarily so. And when it’s not, there isn’t much that journalists can do about it. </p>
<h2>Degrees of dishonesty matter</h2>
<p>The problem is opinion-based journalists – not merely their behavior, <a href="https://www.bostonglobe.com/arts/2015/02/26/bill-reilly-and-growth-partisan-media/SiTny61lsaOFav0QV7szwK/story.html">but their proliferation</a>. </p>
<p>Gone are the days when the public was limited to a few broadcast networks and a few newspapers striving for some form of balance. Today, news consumers can choose from Fox News, MSNBC and Internet news sources of every imaginable persuasion.</p>
<p>Simply by occupying so much space in the media landscape, party-aligned media make it difficult for voters to distinguish between valid criticism of one party and biased reporting from a partisan shill. </p>
<p>In so doing, partisan media make it possible – and worse yet, rational – for voters to dismiss any one-sided criticism as biased, thereby enabling extremism and dishonesty.</p>
<p>Some lies are bipartisan. For example, many politicians will underestimate the cost of their favorite programs, and overestimate their benefits. </p>
<p>Take the architect of modern Republican budgetary policy, Speaker Paul Ryan. While he insists that his goal is to reduce the deficit, his budgets specify large tax cuts <a href="http://www.taxpolicycenter.org/taxvox/paul-ryans-budget-plan-more-big-tax-cuts-rich">but don’t detail how they will be paid for</a>. </p>
<p>On the other side of the aisle, Senator Bernie Sanders <a href="http://krugman.blogs.nytimes.com/2016/02/17/what-has-the-wonks-worried/">has been at odds with liberals like Paul Krugman</a> because his economic plan assumes an absurdly high 5.3 percent rate of economic growth. Part of Krugman’s criticism of Sanders is that he gives critics on the right, as well as those who insist that the parties are equivalent, an opening to argue that Democrats are just as dishonest Republicans.</p>
<p>And then there’s Donald Trump. The man currently leading the Republican presidential contest rose to prominence in the party by promoting the debunked conspiracy theory that President Obama was secretly born in Kenya. </p>
<p>Birtherism is different from conventional, Ryan/Sanders-style dishonesty. It is a lie so absurd that in normal circumstances, journalists can dismiss it. When Trump was pushing the issue in 2011, few journalists in the unaligned press felt the need to grant it plausibility, and they didn’t need to do so because at the time, Trump was little more than a reality TV star. </p>
<p>If he wins the Republican nomination, though, journalists will be unable to dismiss him – no matter how egregiously he lies.</p>
<p>What will Trump say if he gets the nomination? We don’t know, but he has a fondness for peddling absurd conspiracy theories, whether it’s <a href="https://theconversation.com/making-sense-of-the-scalia-conspiracy-theory-55083">suggesting that Justice Scalia was murdered</a> or <a href="http://www.slate.com/blogs/xx_factor/2015/09/16/donald_trump_suggested_vaccines_cause_autism_during_the_cnn_gop_debate_he.html">advancing anti-vaccination myths</a>.</p>
<p>Then there’s Hillary Clinton. Journalistic fact-checking is not without problems, but it can be useful. PolitiFact currently rates <a href="http://www.politifact.com/personalities/hillary-clinton/">28 percent</a> of Clinton’s checked statements as “mostly false” or worse. She isn’t a paragon of honesty, but she didn’t achieve her lead in the Democratic contest by peddling anything comparable to birtherism. </p>
<h2>The bias charge</h2>
<p>Suppose the contest comes down to Clinton and Trump. When covering the race, the unaligned press could obey journalistic norms of balance, and pretend that Clinton’s normal, everyday lies are no different from whatever conspiracy theories Trump might embrace. </p>
<p>The problem is that doing so would not only allow the more egregious liar to escape punishment, but it would actually give candidates incentives to tell even crazier lies. After all, if nobody will call you more dishonest than your opponent, why constrain yourself to the truth?</p>
<p>On the other hand, journalists could point out that one candidate is an ordinary liar, and the other’s dishonesty is world-class. </p>
<p>We know what happens next – the latter complains about media bias. Consider the backlash against Candy Crowley when she intervened on President Obama’s behalf during a 2012 presidential debate. </p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/gfmKpA30Xeo?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">CNN’s Candy Crowley corrects Mitt Romney during a 2012 debate.</span></figcaption>
</figure>
<p>Both parties must agree on presidential debate moderators, and Republicans <a href="http://www.politico.com/blogs/media/2013/02/debate-co-chair-mistake-to-have-candy-crowley-moderate-presidential-debate-157380">will never again agree to let Crowley moderate a debate</a>. Unless journalists want to face that kind of blowback, they must assert that Democrats and Republicans are always equally honest (or dishonest).</p>
<p>Most importantly, what about voters? If a journalist calls one candidate a liar – and that candidate calls the journalist a shill for his opponent – whom should a voter believe? </p>
<p>A voter can think one of two things. Either one candidate is a bigger liar than the other, or the journalist is biased. </p>
<p>But if the media landscape is littered with partisans while the unaligned press continually tells us that both parties are equally dishonest, then the voter’s reasonable conclusion will be that both candidates are equally dishonest, and anyone saying otherwise is just a partisan operative. Distressingly, voters are being rational when they discount one-sided criticism.</p>
<p>And it gets worse. The more often conventional journalists insist that both parties are equally guilty of all sins in order to avoid accusations of bias, the more voters believe it. The more they believe it, the more likely they are to discount any future claims that one party is more dishonest. The whole thing is a vicious cycle.</p>
<h2>Partisan enablers</h2>
<p>Notice that the partisan shills create the problem by existing rather than taking any direct action. </p>
<p>Sean Hannity will always criticize the Democrat and defend the Republican. Al Sharpton will do the reverse. The latter <a href="http://www.salon.com/2011/07/27/sharpton_10/">even admitted</a> that he would never speak ill of President Obama in a 2011 interview with “60 Minutes.”</p>
<p>So if a journalist calls Trump a liar, should voters believe it? Or should they conclude that the journalist is a Democratic shill, like Al Sharpton?<br>
Notice, too, that Sean Hannity is not the one who helps a Republican get away with lying. Al Sharpton enables Republican liars by making it credible for Republicans to accuse any journalists criticizing them of being Democratic shills, like Sharpton. </p>
<p>Meanwhile, Hillary Clinton could lie as brazenly as she wants, and accuse anyone who criticizes her of being part of the “vast, right wing conspiracy” (<a href="https://en.wikipedia.org/wiki/Vast_right-wing_conspiracy">to use the phrase</a> the Clintons popularized in the 1990s). Since Sean Hannity really will call her a liar no matter what, unaligned journalists can only go so far without looking like conspirators. Hannity’s existence merely enables Clinton, if she chooses to go down that path. </p>
<p>Is there a way out? We found one before. In the 19th century, newspapers were party-owned operations who made no pretense to independence or objectivity. The modern concept of journalism didn’t come into being until <a href="http://www.britannica.com/topic/muckraker">the muckracking era</a> at the beginning of the 20th century – in particular, the work of Upton Sinclair, Lincoln Steffens and others who became the progenitors of investigative journalism.</p>
<p>We now operate in something closer to the old system, with a media landscape infested with party-aligned outlets. However, many don’t even acknowledge their leanings, complicating voters’ decisions.</p>
<p>It is possible, though, that Trump changes the rules of the game. </p>
<p><a href="http://theunmutual.blogspot.com/2016/03/the-media-donald-trump-and-andy.html">As I have written elsewhere</a>, the journalistic challenge of trying to interview Trump, who is as much performer as candidate, makes his relationship with the press uniquely conflicted. If his party fails to unify around him, journalists may have political “cover” to point out his more blatant dishonesty.</p>
<p>However, they do so at risk to themselves – a risk created by the mere existence of partisan journalism.</p><img src="https://counter.theconversation.com/content/54533/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Justin Buchler does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A partisan media landscape has made it almost impossible for journalists to avoid charges of bias when calling out a candidate’s dishonesty.Justin Buchler, Associate Professor of Political Science, Case Western Reserve UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/503392015-11-06T16:18:19Z2015-11-06T16:18:19ZJobs report shows why it’s time Speaker Ryan and President Obama sat down for a beer<p>Today’s <a href="http://www.bls.gov/news.release/empsit.nr0.htm">strong employment report </a> is a cause for <a href="http://www.businessinsider.com/october-jobs-report-november-6-2015-11">celebration</a>, at least for now. </p>
<p>The economy reversed the trend of the past three months by creating 271,000 new jobs. The overall unemployment rate is now at 5%, a seven-year low. Growth was especially strong in the service sector, with professional and business services (up 78,000) and health care (45,000) leading the way, followed by retail trade (44,000) and food services and drinking establishments (42,000). </p>
<p>The disappointments were no growth in manufacturing, no declines in long-term unemployed and <a href="http://data.bls.gov/timeseries/LNS11300000">no evidence</a> that those who have given up on finding a job are reentering the labor market.</p>
<p>So overall three cheers for October! But perhaps it is time to get out of the waiting game each month to see if by chance the economy and labor market had a good or bad month (we are terrible at predicting the numbers, considering those who <a href="http://www.fxstreet.com/news/forex-news/article.aspx?storyid=f4193a6a-9349-41ed-9ad6-57f6179a736e">tried</a> thought the October number would be 170,000 or so). </p>
<p>It is time to stop reacting to the monthly numbers and get proactive. Why not set a bold but realistic target to create the number and quality of jobs America needs for the long run? </p>
<h2>Time for a jobs target</h2>
<p>In 1961 President John F Kennedy mobilized the country around his pledge to put a man on the moon by the end of the decade. In doing so, he energized the public, Congress and the private sector to work together to achieve this goal. </p>
<p>We ought to do the same now by setting a target to create 12 million high-quality jobs by the end of this decade. </p>
<p>That is easily doable: the 12-million target translates into 250,000 per month from January 2016 through December 2019. </p>
<p>Meeting this target, however, would require a <a href="https://theconversation.com/us-must-invest-in-its-workers-and-roads-to-sustain-job-gains-37778">proactive effort</a> from the president, Congress, Federal Reserve, business, labor and our schools, exactly the type of collaboration the American public is calling for in this election cycle.</p>
<h2>The Fed’s tired of waiting…</h2>
<p>The conventional economic advice at the moment might be to urge the Federal Reserve to once again <a href="https://theconversation.com/lackluster-jobs-growth-and-stagnant-wages-show-why-the-fed-shouldnt-raise-interest-rates-just-yet-45818">defer</a> on raising interest rates. </p>
<p>That is probably sound advice, but I’d rather have the Fed say, wait a minute, we’ve done our part to support the recovery. It’s time Congress, the White House, and the private sector play their roles.</p>
<p>The timing is perfect for Congress and the president to lead the way. The new speaker of the House, Paul Ryan, has a <a href="http://www.politico.com/story/2015/11/house-passes-6-year-highway-bill-215555">transportation bill</a> on his desk that could be transformed into a <a href="https://theconversation.com/want-a-free-lunch-invest-in-americas-infrastructure-48624">broader infrastructure investment</a> vehicle that would garner strong business and labor support. </p>
<p>He in turn could challenge business and labor to put their own money where their mouths are and commit to jointly funding and overseeing a national infrastructure investment fund. In the spirit of a new beginning, he and the president could sit down (maybe over a good beer brewed in Wisconsin, Ryan’s home state). </p>
<p>They could also set long-term budget targets for investments in basic research, for expanding the number of initiatives aimed at building the next generation of manufacturing industries and for investing in education and training to fill what industry says is a coming – and in some sectors current – middle skills and technical talent shortage. </p>
<h2>Getting the message</h2>
<p>Setting these targets would have both immediate substantive and signaling effects on private sector decision makers. Business would get the message that good opportunities lie ahead and would start expanding capacity and investments in product development. </p>
<p>Labor could be encouraged to expand existing apprenticeships and work with industry to create new ones fitted to emerging technologies and occupations. Technical colleges and universities could be challenged to expand their classroom, online and cooperative and internship programs to provide the next generation workforce with the skills industry will need to fill the new jobs. </p>
<p>These schools could be incentivized to reach out to the long-term unemployment with course work and links to employers that remove the stigma they now carry when searching for work.</p>
<p>In short it is time for America to go beyond waiting for the jobs numbers to surprise or disappoint us each month and take the steps needed to produce predictable and sustained growth that meets a consensus target and puts Americans back to work, and perhaps even get wages moving in the right direction again.</p>
<p>So Mr Speaker and Mr President, go have a beer and see what you can do together. If you want, I’ll buy you both a good Wisconsin brew.</p><img src="https://counter.theconversation.com/content/50339/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Thomas Kochan does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>October was a strong month for jobs gains, but the president and Congress need to stop waiting for the numbers to improve and begin to act more proactively.Thomas Kochan, Professor of Management, MIT Sloan School of ManagementLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/499812015-10-29T18:23:11Z2015-10-29T18:23:11ZPaul Ryan just accepted the worst job in American politics<p>Republicans voted overwhelmingly to make Paul Ryan the new <a href="http://www.nytimes.com/2015/10/30/us/politics/paul-ryan-set-to-take-over-as-speaker-hoping-to-manage-the-chaos.html?module=Notification&version=BreakingNews&region=FixedTop&action=Click&contentCollection=BreakingNews&contentID=53875293&pgtype=article">speaker</a> of the House of Representatives on Thursday, but the Wisconsin congressman has no reason to celebrate. He just got the worst job in American politics. </p>
<p>In theory, the House speaker is an immensely powerful office. Among other things, the House speaker controls when and whether <a href="https://rules.house.gov/about">legislation gets voted on</a>. </p>
<p>But since the late 1980s, the job of House speaker has been a career killer for most of the people who have held the position. </p>
<p>And today the job is harder than ever. </p>
<p>Ryan comes to the speakership at a time when the United States House of Representatives is the most dysfunctional legislative body in the Western world. To succeed in office, Ryan must do something that no other Republican leader has been willing to do: take on the extremists in his own party. </p>
<h2>A dead-end job</h2>
<p>History suggests Ryan has a Herculean task ahead of him.</p>
<p>Since Tip O’Neill retired in 1986, the roster of House speakers reads like a casualty list. <a href="http://articles.latimes.com/1989-06-01/news/mn-1334_1_public-man-ethics-committee-official-conduct">Jim Wright</a>, O’Neill’s successor, was driven from office by a scandal involving his personal finances. <a href="https://www.washingtonpost.com/national/thomas-s-foley-former-house-speaker-dies-at-84/2013/10/18/7d2c7df4-380d-11e3-ae46-e4248e75c8ea_story.html">Tom Foley</a>, Wright’s successor, lost his own congressional seat during the Republican tidal wave of 1994. <a href="http://www.washingtonpost.com/wp-srv/politics/govt/leadership/stories/gingrich110798.htm">Newt Gingrich</a>, the author of the GOP’s stunning congressional victories in ‘94, was subsequently driven from office by an intraparty revolt. And <a href="http://www.washingtonpost.com/wp-srv/politics/special/clinton/stories/livingston122098.htm">Bob Livingston</a>, Gingrich’s designated successor, was forced to resign by a sex scandal before officially assuming his duties.</p>
<p>Ryan’s most recent predecessors did not fare much better. </p>
<p>Despite large Republican majorities in the early 2000s, <a href="http://www.csmonitor.com/USA/Justice/2015/1028/Dennis-Hastert-s-guilty-plea-could-keep-scandal-details-out-of-public-view-video">Dennis Hastert</a> failed to get President George W Bush’s <a href="http://www.slate.com/articles/news_and_politics/the_big_idea/2005/03/bushs_first_defeat.html">social security</a> and <a href="http://www.nbcnews.com/id/19475868/ns/politics/t/immigration-bill-suffers-major-defeat-senate/#.VjIldFWFOUk">immigration</a> reform proposals approved by Congress. </p>
<p>John Boehner ran into the same obstacles. The fundamental problem Boehner faced was his inability to control the House Republican caucus. With a Democrat in the Oval Office and Republicans deeply divided, Boehner <a href="http://www.nytimes.com/2015/09/26/us/next-speaker-will-face-the-same-difficulties-with-conservatives.html">failed</a> to get <a href="http://www.cnn.com/2015/09/27/politics/john-boehner-ted-cruz-conservative-groups/">significant</a> legislation enacted into law.</p>
<p>In recent years, only the Democrat Nancy Pelosi has achieved legislative success as House speaker. With Democrats controlling the White House and Congress in 2009, Pelosi helped shepherd through the House the <a href="http://www.nytimes.com/2010/03/24/health/policy/24health.html?_r=0">Affordable Care Act</a>, the single most important change in American health care since Medicare’s enactment in <a href="http://www.politico.com/story/2007/07/president-johnson-signs-medicare-bill-on-july-30-1965-005129">1965</a>. </p>
<p>But Pelosi’s period of legislative effectiveness was exceptionally brief. Republicans booted her from the speaker’s chair when they won control of Congress in <a href="http://www.foxnews.com/politics/2010/11/02/poll-closing-key-east-coast-races-balance-power-line/">2010</a>. In the end, Pelosi achieved far less as House speaker than Democrats expected she would when Barack Obama took office in January 2009.</p>
<h2>The pernicious Hastert rule</h2>
<p>Now it’s Ryan’s turn to sit in the hot seat. </p>
<p>Like Boehner and Hastert before him, Ryan’s biggest problem is his own caucus. Republicans hold <a href="http://history.house.gov/Institution/Party-Divisions/Party-Divisions/">247</a> of 435 House seats, which on paper is a comfortable majority.
But thanks to a misguided rule adopted by Dennis Hastert, Ryan has a much weaker hand to play than the powerful speakers of the mid-20th century. </p>
<p>Under the traditional majoritarian rules of the House, Ryan could successfully govern from the center like <a href="http://www.nytimes.com/learning/general/onthisday/bday/0106.html">Sam Rayburn</a> in the 1940s and 1950s, <a href="http://bioguide.congress.gov/scripts/biodisplay.pl?index=m000364">John McCormack</a> in the 1960s and <a href="http://www.pbs.org/wgbh/americanexperience/features/biography/carter-oneill/">Tip O’Neill</a> in the 1970s and 1980s. All Ryan would need is a bipartisan coalition of 218 Republicans and Democrats to get legislation through the House.</p>
<p>But Hastert changed the House’s rules in the early 2000s. In the process, he empowered the arch-conservative wing of House Republicans to block legislation. </p>
<p>As speaker, Hastert would allow floor votes only on issues that had majority support within the Republican caucus. The <a href="http://www.theatlantic.com/politics/archive/2013/07/even-the-aide-who-coined-the-hastert-rule-says-the-hastert-rule-isnt-working/277961/">Hastert Rule</a> effectively gave a legislative veto to the 110-120 most conservative House Republicans. Even if a bill had the support of over 300 members of Congress, Hastert would not allow a vote to be taken if it lacked the support of a majority of Republicans. </p>
<p>As House Speaker, John Boehner <a href="http://thehill.com/homenews/house/306179-boehner-commits-to-hastert-rule-on-immigration-reform">lacked</a> the political <a href="http://www.politico.com/story/2013/06/john-boehner-hastert-rule-immigration-093511">courage</a> to dump the Hastert Rule. Only in the last few days did Boehner finally show independence and defy the far right wing of his caucus by negotiating a modest but sensible <a href="http://www.nytimes.com/2015/10/28/us/politics/congress-white-house-budget-deal-boehner.html">budget deal</a> with the White House. </p>
<p>But it was too little too late. Boehner left office on Thursday as one of the <a href="https://www.washingtonpost.com/news/the-fix/wp/2014/07/09/the-113th-congress-is-historically-good-at-not-passing-bills/">least effective</a> House speakers in history.</p>
<h2>The Tip O’Neill model</h2>
<p>Ryan must learn from Boehner’s mistakes. </p>
<p>To that end, Ryan should model his speakership on Tip O’Neill, the legendary Democratic speaker of the House. Although Democrats held big House majorities throughout O’Neill’s tenure, O’Neill worked closely with <a href="http://www.nytimes.com/roomfordebate/2015/10/23/paul-ryan-the-hastert-rule-and-democracy-on-the-hill/paul-ryan-would-obstruct-democracy-by-backing-the-hastert-rule">Republicans</a>, including President <a href="http://www.csmonitor.com/Commentary/Common-Ground/2013/1205/Budget-negotiators-take-heed-The-art-of-the-deal-according-to-Reagan-and-Tip-O-Neill">Reagan</a>. Together they modernized the tax code, saved social security, passed comprehensive immigration reform, and funded a defense buildup that helped win the Cold War. </p>
<p>O’Neill realized that in order to pass legislation that stands the test of time, the speaker must take a bipartisan approach. </p>
<p>Ryan would be wise to follow in O'Neill’s footsteps. If Ryan embraces bipartisanship, he has a historic opportunity to restore legislative authority and political effectiveness to the House speaker’s office. </p>
<p>But if Ryan cowers before the obstructionist arch-conservatives as Boehner did, the position of House speaker will remain the worst job in politics.</p><img src="https://counter.theconversation.com/content/49981/count.gif" alt="The Conversation" width="1" height="1" />
<h4 class="border">Disclosure</h4><p class="fine-print"><em><span>Anthony J Gaughan is a registered independent. </span></em></p>To make it work, he’s going to need to be braver than Boehner.Anthony J. Gaughan, Associate Professor of Law, Drake UniversityLicensed as Creative Commons – attribution, no derivatives.