The Coming War On Medicare and Medicaid

With the nomination of Tom Price as Secretary for Health and Human Resources (HHS), Trump has clearly signaled his support for an all-out Republican attack on Medicare and Medicare, two of the longstanding pillars of America’s health-care system.
Since 1966, when it was first established as a single payer, national social insurance program administered by the federal government, Medicare has grown to the point where it now provides health insurance for over 55 million Americans — 46 million people age 65 and older and nine million younger people with disabilities recognized by the Social Security Administration. The federal government contracts with about 30-50 private insurance companies across the U.S. to administer the program, and it is primarily funded by a Payroll Tax, premiums and surtaxes from beneficiaries, and general revenues to make up any shortfall. On average, Medicare covers about half of the health care charges for those enrolled. The enrollees must then cover their remaining costs either with supplemental insurance, separate insurance, or out-of-pocket. Out-of-pocket costs can vary depending on the amount of health care a Medicare enrollee needs, and uncovered services—such as for long-term, dental, hearing, and vision care—may be covered though supplemental insurance premiums.
Medicare, by contrast, is a needs-based health insurance program financed jointly by the federal government and the states, and administered by the states. It was first established as part of the 1965 Amendments to the Social Security Act. Beginning in the 1980s, many states received waivers from the federal government to create Medicaid managed care programs. Under managed care, Medicaid recipients are enrolled in a private health plan, which receives a fixed monthly premium from the state. The health plan is then responsible for providing for all or most of the recipient’s healthcare needs. Today, all but a few states use managed care to provide coverage to a significant proportion of Medicaid enrollees. As of 2014, 26 states had contracts with managed care organizations (MCOs) to deliver long-term care for the elderly and individuals with disabilities. Nationwide, roughly 80% of enrollees are enrolled in managed care plans.
Starting in 2014, the Affordable Care Act expanded Medicaid coverage, providing health care coverage to millions of additional Americans who previously were not eligible for government-sponsored health insurance programs. Under the law as written, states that wished to participate in the Medicaid program would be required to allow people with income up to 133% of the poverty line to qualify for coverage, including adults without dependent children. The federal government would pay 100% of the cost of Medicaid eligibility expansion in 2014, 2015, and 2016; with some funding by the states thereafter.
However, the Supreme Court ruled in NFIB v. Sebelius that this provision of the ACA was coercive, and that the federal government must allow states to continue at pre-ACA levels of funding and eligibility if they chose. Several states then opted to reject the expanded Medicaid coverage provided for by the act, which impacted over half of the nation’s uninsured living in those states, which include Texas, Florida, Kansas, Georgia, Louisiana, Alabama, and Mississippi. These states were followed by Alaska, Idaho, South Dakota, Nebraska, Wisconsin, Maine, North Carolina, South Carolina, and Oklahoma, which either decided to reject expanded coverage, or are likely to do so. Unsurprisingly, all or almost all of the states that have rejected expanded coverage through Medicaid under the Affordable Care Act are Red States that broke in favor of Trump in the 2016 Presidential election. This means that expanded Medicaid coverage under the ACA applies almost exclusively to poorer people in Blue States, which have the most to lose if the ACA and its expanded Medicaid coverage were to be repealed.
Republicans such as Speaker Paul D. Ryan and Tom Price have supported proposals to revamp the structure and to “privatize” Medicare by providing Medicare participants with vouchers that they can use to get health coverage with private insurance companies. If these proposals are pursued, they would severely hurt older and sicker Americans who rely upon Medicare for their basic medical coverage. Knowing that this attack on Medicare is coming, Democrats have already started mobilizing their efforts to resist these efforts as vigorously as necessary. Medicare is one of the basic compacts with American citizens, very similar to Social Security. In other words, if you have contributed with payments into the system through payroll tax deductions from your paycheck during you working years, then you are entitled to health coverage under Medicare when you reach age 65. Any Republican proposal to tinker with this basic compact should be met with a firestorm of protest across the country, and rightfully so.
The coming war to dismantle Medicaid will be much more troublesome, since the general public has less of an understanding of the Medicaid program than they do about Medicare, and since it is “needs based,” and is primarily designed to provide health benefits to those millions of children, seniors, working families and people with disabilities who are at the lower rungs of the economic ladder, the constituency of those supporting Medicaid is smaller and less well organized than for Medicare. Ironically, a substantial portion of those millions of Americans who voted for Donald Trump are receiving basic (but not necessarily expanded) Medicaid coverage in their respective states, and they would likely to be stripped of their health insurance coverage if the Medicaid system were to be dismantled.
The Republican effort to dismantle Medicaid is much more likely to be successful, if for no other reason than Medicaid recipients are generally poor, and this kind of “safety net” program and this demographic group has never been high on the list of those that the Republican Party and Mr. Trump have ever really cared about. Both Speaker Paul D. Ryan and Tom Price have made proposals to deeply cut Medicaid through arbitrary block grants or “per capita caps,” and during the campaign, Trump has also proposed block grants.
Trump will, no doubt, continue to make perfunctory reference to his commitment to the Forgotten Men and Women of America’s Heartland who voted overwhelmingly for him, but there can be no serious doubt now that his overall economic and fiscal strategy will be designed to benefit the mega-rich and well-to-do at the expense of the tens of millions of Americans who are living paycheck to paycheck, or who rely in government programs such as Social Security, Medicare or Medicaid to just scrape by.
Trump and HHS Secretary-designee Price will no doubt attack Medicare as a “bloated and wasteful system” that needs to be deeply pruned on fiscal responsibility grounds alone. Mr. Price’s own proposal, which he presented when he was the chairman of the House budget committee, would cut Medicaid by about $1 trillion over the next decade, and this cut would be on top of the reduction that would result from the repeal of the Affordable Care Act, which both Mr. Trump and Republican leaders are advocating. Together, full repeal and block granting would cut Medicaid and the Children’s Health Insurance Program funding by about $2.1 trillion over the next 10 years, amounting to a 40 percent cut. Even without counting the repeal of the A.C.A. coverage expansion, the Price plan would cut remaining federal Medicaid spending by one-third, or $169 billion, by the 10th year of his proposal, with the reductions growing more severe thereafter. In terms of the number of Americans who would be stripped of Medicaid coverage, the Henry J. Kaiser Family Foundation estimated that a similar Medicaid block grant proposed by Mr. Ryan in 2012 would lead to 14 million to 21 million Americans losing their Medicaid coverage by the 10th year, and that is on top of the 13 million who would lose Medicaid or children’s insurance program coverage under an ACA repeal. A large percentage of those who would lose their Medicaid coverage would be Trump supporters in Red States. Are they in for a big surprise as to what the election of President Trump has wrought!
Fortunately, Democrats and others who plan to resist the Republican stampede to gut Medicaid have facts and history on their side (to the extent that those are of continue relevant in a Trump “post-fact” world. The overwhelming weight of the evidence showing that Medicaid’s actual spending per beneficiary has, on average, grown about 3 percentage points less each year than it has for those with private health insurance. According to the Center on Budget and Policy Priorities, this long-term trend that is projected to continue. Since Medicaid is being managed relatively efficiently, this means that the imposition of any arbitrary spending caps being proposed by Mr. Price and Mr. Ryan would leave no alternative for states other than to impose harsh cuts in benefits and coverage.
The emerging Republican plan to “repeal, delay and replace” the ACA would only delay the disastrous consequences. Current Republican plans to eliminate the marketplace subsidies and ACA Medicaid expansion starting in 2019 would create what has been called a “health care cliff” where the disappearance of all Medicaid funds and subsidies for ACA in 2019 would mean that about 30 million people would lose their health care coverage. Democrats and any sensible Republican allies now have two years (2017 and 2018) to prevent this looming disaster.
This doomsday scenario would not only impact low-income families, but it would also hurt tens of millions of middle-income families who have a family member with a disability, such as autism or Down syndrome, or are in need of nursing home care. About 60 percent of the costs of traditional Medicaid come from providing nursing home care and other types of care for the elderly and those with disabilities. Trump and the Republican leadership are giving every indication that they are prepared with the political consequences such a drastic cut in coverage.
The big question is whether they can be stopped. Now is the time for the Democratic Resistance to start organizing for this coming battle and, who knows, only three Republican Senators need to be convinced of the righteousness of this cause for the Republican juggernaut and war against Medicare and Medicaid to be stopped in its tracks.

Christmas 2016

On this Christmas Day, thoughts of peace, hope and love naturally come to mind. But it would be wrong to idealize what occurred in the small town of Bethlehem over two thousand years ago through the gauzy mist of history. Yes, if you are Christian, a truly miraculous event occurred on that day. The Son of God was immaculately conceived and born to a young Jewish woman. Even our Muslim brethren believe – according to the Quoran — that Jesus was a truly great Jewish prophet who was immaculately conceived when God breathed life into the Virgin Mary’s womb. Of course, Muslims believe that this great prophet was later eclipsed by the Prophet Mohammad, but that’s another story for another day. After all, this is Christmas.
Over two thousand years later, it is important for us to remember that these dangerous and troubled times we live in are not dissimilar to the world into which Jesus was born. Oppressive local despots dominated much of the Roman Empire, ruling with an iron grip with the consent of the Roman Emperor Augustus, so long as they dutifully paid taxes and tribute to Rome. In Judea, Herod the Great was appointed as King of the Jews by Rome. A census was underway, which is why Joseph and Mary were traveling back to Joseph’s birthplace in Bethlehem so that they could be properly recorded in the census.
Their circumstances were exceedingly precarious. Joseph and Mary were engaged, but not married, and yet Mary was almost nine months pregnant with child. Imagine what Joseph and Mary must have thought, since they knew full well that they had never had carnal relations, and yet here she was pregnant! Very upsetting, to be sure. And this meant that the couple was about to have a child out of wedlock, which no doubt drew criticism from devout Jews all along the arduous route that they were travelling. Long distance travel was hard enough at the time in the best of circumstances, but travelling while pregnant must have made the ordeal almost intolerable. On top of all this, when they finally made it to Bethlehem, no doubt exhausted from trip, they couldn’t even get a room at the inn. The Inn was either fully occupied with other travelers, or the innkeeper didn’t feel it was appropriate to give a room to an unmarried couple, with the woman obviously pregnant.
Sleeping in a manger may sound romantic from a distance, but did you ever try sleeping in a barn filled with farm animals mucking about? Believe me, it is no picnic. Of course, a visit from the Magi and a few shepherds who followed a shining star to Bethlehem provided a welcome break, but giving birth in a barn without the benefit of an anesthetic or even a mid-wife to assist must have been close to torture for Mary. It’s a miracle that the mother and boy both survived the ordeal relatively intact.
But this was just the beginning of their troubles. According to the Gospel of Matthew, Herod ordered the execution of all young male children in the vicinity of Bethlehem, so as to avoid the loss of his throne to a newborn King of the Jews whose birth had been announced to him by the three Wise Men, also known as the Magi.
Herod himself, according to Matthew, had directed the Magi to Bethlehem, and instructed them to report back to him if in fact they found the king they were looking for. However, after they found Jesus and honored him, they were warned by an angel not to alert Herod, and they returned home by another route. When the Magi had gone, another angel appeared to Joseph in a dream, directing him to get up and take the child and his mother to Egypt, which he did.
When Herod realized that he had been outwitted by the Magi, he was furious, and he gave orders to kill all the boys in Bethlehem and its vicinity who were two years old or under, in accordance with the time frame he had learned from the Magi. This has come to be known as the Slaughter of the Innocents. Jesus and his family escaped only because they were in Egypt, where they remained until Herod’s death. And when they returned to Judea, the peaceful and tranquil life of a carpenter didn’t last very long for Jesus. He started preaching the gospel of love and peace, and performed a few miracles, but his temper sometimes got the better of him, like when he threw the money changers out of the Temple. And then the inevitable happened. He was too much a threat to the Jewish and Roman authorities that he had to be silenced, in brutal fashion. Crucifixions have apparently gone out of fashion as a strategy for both punishment and torture, but President-elect Trump has promised that waterboarding “and worse” will continue under his watch, and the Guantanamo Bay facility will continue to be very much open for business, despite the dearth of actionable intelligence that our “enhanced stress” techniques have been produced. But that is not really the point, is it? For thousands of years, torture has primarily been used to humiliate and degrade other human beings to the point where they can be viewed as sub-human. It degrades both the torture victim and the torturer, and yet our so-called “civilization” has not progressed to the point where torture, beheadings and mass killings are a thing of the past. They are very much with us still in the present, and at the rate we are going, we can expect them to be with us for the foreseeable future.
As the French proverb goes, “The more things change, the more they remain the same.” Just last week, the world watched in horror and frustrated impotence as hundreds if not thousands of innocents were killed in the siege of East Aleppo in Syria. The Assad Regime, Iran and Russia seemed to have formed a winning coalition, and in an uncertain world, one certainty is that the Syrian conflict will be continue to be as ugly and brutish in 2017 as it has been in 2016. Russia will continue its efforts to rebuild its Empire by absorbing parts of Ukraine and perhaps other neighboring states, and it is doubtful that, with Western Europe in disarray and a President Trump in the White House, any of the traditional “liberal democracies” will have the inclination or political will to stop the steady spread of authoritarianism throughout the world.
The prospects for the coming year are beak, but not totally hopeless. America has seen dark days before and survived – indeed, thrived – through periods of turmoil and depression. We survived a Civil War, a Great Depression, two World Wars, and even a Great Recession, so there is no reason to believe that continuing a permanent war footing against terrorism and a Trump Presidency will do us in. After all, short of a nuclear Armageddon, there is really nothing that a President Trump can do to permanently damage and dismantle our democratic institutions. Unlike his idol, Vladimir Putin, an American President has vast powers, but not total power. We still have a system of checks and balances, and if his real intention, as signaled by his Cabinet appointments, is to dismantle or neuter the EPA, Department of Energy, the Interior and Labor Departments, and other agencies that have served the country well for decades, then he will have a serious fight on his hands, and the Democrats in Congress and even some sensible Republicans have vowed to fight to the death to preserve these essential elements of our modern democracy and social system.
But nothing is pre-ordained. Nothing is for certain, and nothing can be taken for granted. We may wish to think that America is so special that its continued existence is part of some Great Cosmic Plan, but the reality is that history teaches us that empires rise and empires fall, and none to date have lasted forever. We have collectively assumed that America is an exception to this inexorable rule, and only time will tell whether American Exceptionalism is a reality or just a myth. The truth is that America has survived and thrived for over 200 years because each generation of Americans has faced and overcome the challenges that faced this great nation. Preserving our democratic ideals and institutions is hard work, and just when we thought that we were making progress in eradicating the last vestiges of racism, bigotry and prejudice in this country, we have been shocked out of our complacency by a Presidential campaign that seemed to be driven by divisiveness and the worst impulses of our human nature. With the raw divisions exposed in our country, we are poised to move forward or backwards, but will never be the same again. America has gone backwards before, and it could do it again. It is entirely up to us. The Civil War was followed by Reconstruction, where the freed slaves in the South were given civil and voting rights, albeit under the watchful eye of occupying federal forces. When the federal troops were withdrawn in 1877, as part of the Great Compromise that propelled Rutherford B. Hayes into the White House, the Jim Crow laws largely stripped African-Americans of their civil and voting rights, reducing many of them back to virtual peonage and snatching the American Dream from their grasp.
Someone once said that each generations of Americans have gotten the President that was needed, or the one that they deserved. Perhaps a President Trump is what America deserves. It is a country as deeply divided as at any time in our country’s history since the Civil War. There are Blue States on both coasts, and mostly Red States in between, with virtually no one willing or able to talk to or listen to the other side. There is much shouting, posturing and bombast abroad in the land, but not much thoughtful reflection on what path we should take to restore and reinvigorate our democratic institutions and to heal the wounds that so deeply divide us.
Only eight short years ago, America and the world were filled with hope that President Obama would be able to unite Americans and bridge the deep gorges that seemed to divide us. Remember the talk about there not being Red States or Blue States, only the United States? It seems so long ago. The Great Recession was in full swing, with the economy and financial system in a virtual free-fall. A massive stimulus program had to be quickly put in place that gave the American people an ownership share, at least on a temporary basis, of huge chunks of the auto industry and the financial sector. The economy and financial structure survived, and have actually thrived since those dark days. The economy has been expanding at a steady pace, and unemployment is down nationwide. Nevertheless, the pace of economic recovery has varied greatly throughout the country, with the East and West Coasts generally surging and leading the recovery, while the rural and traditional manufacturing centers of the Midwest and South lagging far behind. These Forgotten Americans – largely white and generally not very well educated or skilled – who voted overwhelmingly for Trump. They can be forgotten no more. Whether Trump genuinely was concerned about the plight of these Forgotten Americans or not, only time will tell. All indications seem to be that they will be forgotten once again as the Trump Administration is rapidly filling up with billionaires and plutocrats who don’t care one whit about the average unemployed or underemployed white men and women who turned out in droves for the Trump rallies throughout Middle America and still proudly wear their Make America Great Again hats and tee-shirts. Boy, are they in for a rude shock when Trump and the Republican Establishment repeals the Affordable Care Act, privatizes Social Security and Medicare, and wages war on ordinary working people through their own Labor Department.
Only time will tell. In the meanwhile, let’s do more than just hope for the best. We must redouble our efforts in the coming year to do everything in our power to preserve and protect our democratic principles and institutions, which are proving to be far more fragile than anticipated. When asked what kind of government we have, Benjamin Franklin, emerging from the Continental Congress, said: “A Democracy, if you can keep it.”
American Exceptionalism is over. We are but one of several Western liberal democracies that are under severe stress and susceptible to the siren call of national populist leaders that promise a return to the good old days that either never were or will never be again. Trump’s call to fearful Americans that a ban on Muslim immigration or the building of a Wall will save them from the ravages of a rapidly changing future is as seductive as it is hollow. But we will survive Trump as we have survived numerous other trials over time. The Democratic Resistance Movement is alive and well, and the Democratic Party will finally be forced to renew the faith of the Forgotten Americans who once were an essential part of their coalition. Then America will truly be Greater, not Again, but Greater than it ever was.
Dated: December 25, 2016
Charleston, South Carolina


On March 12, 1799, Alexander Hamilton published Federalist Paper No. 68, which explained that the Electoral College was designed to prevent the catastrophe that this Country now faces, namely, the ascendency to the Presidency of a person who is unqualified to hold that high office. With the announcement of the CIA Report the election of Donald Trump may also well be the product of foreign interference and meddling in the electoral system, exactly what our founder tried to avoid by establishing the Electoral College.
Hamilton wrote in Federalist 68 that the electoral college was specifically designed to prevent the election of a President who was the product of a “cabal, intrigue, and corruption,” and to thwart any attempt by “deadly adversaries of republican government … [and] foreign powers to gain an improper ascendant in our councils.”
Hamilton envisioned that an existential crisis might emerge for the new Republic where a foreign power could take control of the United States by “raising a creature of their own to the chief magistracy of the Union …[by] tamper[ing] with [the election process] beforehand to [cause voters to] prostitute their votes…” for the sole purpose of electing a President secretly chosen by that foreign power.
In such a dark and dangerous situation, where a foreign power has rigged the election, the Electors would then save the day and the Republic. They would do this by exercising their independent judgment and common sense to prevent the election to the Presidency of a person selected primarily by that foreign power, and not by the will of the People of the United States:
Thus without corrupting the body of the people, the immediate agents in the election [i.e. the Electors] will at least enter upon the task free from any sinister bias. Their transient existence, and their detached situation, already taken notice of, afford a satisfactory prospect of their continuing so, to the conclusion of it, [i.e., the selection of a qualified candidate for the Presidency who is not the product of foreign meddling].
Hamilton emphasized the importance of the task delegated to the Electors by the various states and by the entire Union since they are to be “a special body of representatives, deputed by the society for the single purpose of making the important choice.” Hamilton described the mission of the Electors to be one of “moral certainty, [in order to guarantee] that the office of President will never fall to the lot of any man who is not in an eminent degree endowed with the requisite qualifications and who does not merely possess “talents for low intrigue, and the little arts of popularity.]”
Two hundred and twenty-eight years later after Federalist 68 was written, the Electoral College will have the solemn and awesome responsibility of deciding whether Donald Trump, an unqualified candidate for the Presidency be elected. Donald Trump who is poised to ascend to this high office based on not only his “talents for low intrigue” but, more significantly, as a result of outright cyber warfare. There is no longer any doubt that there was illegal hacking of critical databases and a concerted campaign of disinformation by the intelligence services of the Russian Government. This effort was led by Russian’s autocratic leader, Vladimir Putin. His intention was to not only disrupt the 2016 Presidential election and to undermine confidence in the American electoral process, but to specifically elect a man who has demonstrated time and time again that he is prepared to compromise vital U.S. interests both at home and around the globe. These interest include supporting Russian interest in Crimea, Eastern Ukraine and the Baltic Republics who are members of NATO. Trump is only interested in one thing, serving the long-term tactical and strategic interests of Russia and President Putin.
If the Electoral College does not do its job and prevent Donald J. Trump from taking office, America will be faced with a crisis of unprecedented proportions. Vladimir Putin will have achieved an espionage coup beyond even his wildest dreams: a Manchurian Candidate in the White House!