Anyone who doesn’t “get” Trump’s appeal is said to live in a “bubble.” This means that a substantial majority of Americans are bubble dwellers, because Trump’s disapproval ratings have been hovering between 54 and 60 percent in Gallup’s most recent surveys.
.. The cost of all this is very high. Our political discussion is being brought down by Trump’s self-involvement, his apparent belief that he can only win if he identifies an enemy to attack, and his refusal to make extended and carefully thought-through arguments about anything of substance. Spectacle drives out problem-solving. Our national attention span, never one of our strongest suits, follows Trump down to a level that, in fairness to children, cannot even be called childlike.
The health-care debate is the obvious example. The Republican Congress spotlights “repealing Obamacare.” But this is simply a slogan. What Trump and his party said they’d create was a better health-care system — “something great,” he enthused.
.. A functioning democracy would grapple in a bipartisan way with how to cover everyone more cost-effectively.
.. Trump will declare anything the GOP pushes through — no matter how many of the people who voted for him lose insurance — a “win.” That is all that matters to him.
.. If there was anything useful about the Trump campaign, it was the extent to which it forced Americans who live in thriving parts of the country to notice how badly other regions are doing and how angry many of the people who live in those beleaguered communities are.
.. But where are the practical remedies to help those workers find better-paying jobs? What they get from Trump are mostly symbols
.. Trump announced that thanks to his intervention, a Carrier plant in Indiana would keep at least 1,100 jobs in the United States. But last month, Carrier announced it was cutting 632 jobs from an Indianapolis factory and moving them to Mexico. It’s not clear what Trump accomplished — or if he cares.
.. employment in the nation’s auto plants is down from a peak of 211,000 last year to 206,000.
.. his budget cuts could cost more than 5 million American workers access to job training, job-search assistance and career-development programs.
.. Nothing should be more important to Trump’s presidency than keeping his commitments to workers in states such as Pennsylvania, Michigan and Wisconsin. But these don’t fascinate the president nearly as much as his vendettas and his role as a cable-news critic.
Are the GOP’s Proposed Medicaid Reforms Mean?
Trump has repeatedly praised Canada’s health-care system, which has a very similar structure to Medicaid, as offering a model for the United States to emulate. However, the reforms proposed in both the House and the Senate bills would in fact bring Medicaid even closer to the structure of Canada’s health-care system — only with a far more generous level of funding.
.. Canada’s federal funding system was established in 1957, with the national government providing one dollar for every dollar that provinces spent on hospital and physician services. By the 1970s this arrangement was widely recognized to be causing costs to soar, and the Liberal prime minister Pierre Trudeau reformed this “Canada Health Transfer” so that provinces would receive a fixed annual allocation from the national government.
.. The U.S. Medicaid matching payment to states ($344 billion, or $1,071 per American, in 2015) already well exceeds the Canadian block grant to provinces (US$26 billion, or US$716 per Canadian) — even though the Canada Health Transfer is supposed to cover Canadians of all ages and income levels, whereas Medicaid is dedicated to 21 percent of the U.S. population with low incomes.
.. U.S. federal taxpayers spend an additional $646 billion on Medicare, and $122 billion on other health entitlements such as CHIP or VA — yielding total federal health-care entitlement spending of $3,461 per capita.
.. Canada is not getting more value for money; it is just getting fewer services. Canada’s federal payment doesn’t cover prescription drugs; only hospital and physician services are paid for. Canada also saves money by rationing operating-room time and the ability of physicians to order costly services.
.. Nor does Canada pay significantly less for its physicians than the United States; it just limits access to the expensive ones. In 2010, family physicians earned incomes (net of practice expenses) averaging $159,000 in the United States and US$156,000 in Ontario, while cardiologists averaged $325,000 in the United States and US$283,000 in Ontario. According to the World Bank, the United States has 2.45 and Canada 2.07 physicians per 1,000 inhabitants, while the United States has 0.55 specialist surgeons per 1,000 and Canada 0.35.
.. Waiting lists save lots of money because some patients get better by themselves, others give up seeking care, and a substantial number die before receiving treatment.
.. the allocation of federal payments by open-ended matching has caused funds to be distributed according to how much states can themselves afford to put in. As a result, the states that need help the least received the most assistance. In 2015, Connecticut collected $12,240 in federal Medicaid funds per resident under the poverty line, whereas Alabama received only $4,070.
To keep funds from being captured by the richest states (which generally use them to expand eligibility to wealthier individuals who mostly already had private coverage), it therefore makes sense to cap the increase in funding that each state is able to claim from the federal government every year.
.. The Canada Health Transfer currently increases the funds received by each province at a standard rate of 3.0 percent every year. By comparison, the House GOP’s proposed reform would limit the annual increase in federal payments claimed by each state to a statistic that has increased around 7.0 percent for spending on the aged and disabled and 4.9 percent for that on able-bodied adults and children
President largely sidesteps the bully pulpit in pushing health-care bill
With the Republican push to revamp the Affordable Care Act stalled again, even some allies of President Trump question whether he has effectively used the bully pulpit afforded by his office and are increasingly frustrated by distractions of his own making.
.. The lackluster sales job, combined with recent controversial tweets and public statements targeting the media, has diminished the focus on the president’s leading legislative priority at a key juncture in the Senate, allies and analysts say.
“It’s a mystery,” said Barry Bennett, a Republican operative who advised Trump’s campaign last year and remains close to the White House. “I don’t know what they’re doing.”
.. Trump’s public efforts to dismantle the health-care law, however, contrast sharply with President Barack Obama’s efforts to build support in advance of its 2010 passage. Obama gave a joint address to Congress on health care. He fielded questions at town hall meetings around the country. And he even bantered on live television with hostile lawmakers at a Republican retreat.
.. Not only has Trump been unsuccessful at swinging public opinion toward the legislation, but also “he hasn’t really tried that much,”
.. It’s not hard to imagine other things Trump could be doing to try to boost support for the GOP plan among the public and, by extension, on Capitol Hill, Bennett said.
Trump could make much better use of Twitter, urging his 33 million followers to call their senators and ask them to back the GOP bill, Bennett said... Trump could have visited several states last week, holding events that highlight the sharp rise in premiums under Obamacare.. “You use the model that works for you,” Spicer said, noting that Trump has advanced a health-care bill further in the process at this point in his term than Obama. The ACA did not pass until the second year of Obama’s first term.“We’ve been more efficient,” Spicer said.
Going Small on Health Care
The Democratic bill in 2010 delivered significantly to the party’s base; the Republican bill in 2017 delivers significantly only to the party’s donors.
.. In order to mitigate its unpopularity, Senate Republicans keep making their bill more like, well, Obamacare, which raises the question of why they’re attempting something so complex for such a modest end.
.. the smaller bill would repeal the individual mandate requiring the purchase of health insurance. It would replace it, as the Senate bill does, with a continuous-coverage requirement — a waiting period to purchase insurance if you go without it for more than two months.
.. Instead of wringing almost $800 billion out of Medicaid over 10 years, it would try to reduce the program’s spending by $250 billion — just enough for deficit neutrality.
.. That’s it. That’s the whole thing. Eliminate the hated mandate, keep the exchanges stable, cut a few health care taxes, and pull Medicaid spending downward. Pass the package, declare victory, and pivot to tax reform.
.. Republicans could campaign in 2018 on the credible claim that they had maintained Obamacare’s coverage for most people who wanted it, while reducing its burdens on those who don’t.
.. the Republican Party is too divided on health care, too incompetently “led” by its president, and too confused about the details of health policy to do something that’s big and sweeping and also smart and decent and defensible.