The cynical, possibly winning 25-state strategy behind the Cassidy-Graham ACA repeal bill

Me at

“When Senators McCain, Collins, and Murkowski cast their fateful votes, pretty much everyone assumed that ACA repeal had reached its politically ignominious end. The klieg lights, cable TV, and the front page shifted to hurricanes Harvey and Irma. President Trump announced he would let DACA expire. Democratic leaders Chuck Schumer and Nancy Pelosi negotiated what appeared to be a tactically brilliant three-month extension of the debt ceiling. Senator Sanders released his single payer plan. The Senate HELP committee began the process of discussing a much less ambitious, bipartisan bill. The world kind of moved on.

Only a cloud no bigger than a man’s hand was still up there, called the Cassidy-Graham bill. At first, it seemed like a bit of a joke. Arcane Senate rules impose a final deadline of September 30 to pass an ACA repeal based on a simple Republican majority vote. For weeks, no one in Washington took Cassidy-Graham very seriously.

Until late last week….”

Basic strategy: Impose punishing cuts on California and New York. That frees up a lot of cash to buy up small red-state Senate votes..

What can you do? Call your Senator and your Republican governor.

The Trumpcare toolkit is very useful in showing you how.

You know where they really need the public option? Trump Country.

I don’t know why people are focused on President Trump, when I have cool cartograms of which U.S. counties are down to only one ACA marketplace plan.

Map produced by Todd Schuble. Red and blue shades indicate governor’s party affiliation as of Election Day, 2016.


Cartogram produced by Todd Schuble. Red and blue shades indicate governor’s party affiliation as of Election Day, 2016.

The cartogram is weighted by population, and illustrates four important facts about America and health reform:

  • The standard U.S. map does not accurately reflect the experience of most people. Americans cluster on the coasts and in densely-populated metropolitan areas. Sparsely-populated areas such as northern Nevada or Montana that cover many square miles are over-represented in the standard maps. And these maps distort our understanding. If cattle and corn fields bought health insurance, we’d have a reasonable fear that ACA is collapsing. That’s not the reality.
  • Democrats are terrible at winning down-ballot elections away from the bicoastal liberal states. That’s a huge political consequence of the Obama era.
  • Republicans are terrible at operating successful ACA exchanges. Only one big blue metropolitan area-Philadelphia, PA, was down to one plan. Basically, every other major struggling area is in a red state. Huge sections of the deep south, Arizona, Oklahoma, and the mountain states are down to one marketplace plan.
  • Rural areas such as northern Nevada are terrible places for marketplace competition. They are too sparsely populated to support real competition.

ACA marketplaces may never work very well in sparsely-populated rural areas. Hence a great irony. Trump country may be the locale in greatest need of a Medicare or Medicaid alternative to private plans. Democrats would face a knife fight to enact a public option. Once it’s enacted, I suspect Trump country would never let it go.

More from me here, at

Universal coverage is the proper Democratic rallying cry moving forward

Democrats from Joe Manchin to Bernie Sanders are doing a great job uniting in defense of the Affordable Care Act. Moving forward, there is a risk we will form a circular firing squad around support or opposition to single-payer health care. A better approach is to unite around universal coverage, and around various forms of the public option, so that consumers can buy into Medicare or Medicaid if they so choose.

More from me here, in a tome at Democracy Journal.

A missed opportunity to report on the rural opioid crisis

Columnist Salena Zito wasn’t very candid with me in a recent Twitter exchange. That’s annoying. More important, she’s missed a real opportunity to contribute genuine reporting on the rural opioid crisis.

Twitter generally conveys the emotional warmth of a contentious economics seminar without the intellectual rigor. Still, I’ve come to value my Twitter engagements with kindred spirits and others with whom I deeply disagree whose insights I value.

Ms. Zito is one person I hoped to learn from across the usual partisan and ideological lines. She is a conservative reporter and commentator who writes for the Washington Examiner, New York Post, CNN, and other outlets. Ms. Zito is most famous for her aphorism that “the press takes [President Trump] literally, but not seriously; his supporters take him seriously, but not literally.” This is a genuinely valuable insight into how political professionals underestimated Trump’s electoral appeal. (It is also a profound moral evasion, but that’s another matter.)
Continue reading “A missed opportunity to report on the rural opioid crisis”

BCRA and the disability community

I’ve been doing some writing for Slate these days. I wrote a long and profound piece on BCRA and disability here.

Just today, I did a podcast with Jordan Weissmann. I bloviated, but it was fun. I have to raise my podcast game.

The best part was schooling Jordan on BCRA by making analogy to Jay-Z and Rihanna’s relationship woes. Still not sure why he kept laughing when I was trying to make a serious point.

Another Modest Proposal on health insurance

Follow the logic of ACA repeal and ban employer health insurance (irony alert).

I am shocked, shocked to discover that no less than 155 million Americans are forced by employers to take a substantial part of their pay (or the family breadwinner’s pay) in the form of health insurance. Health insurance they have not chosen, but has been forced on them. Republicans cannot be content with the repeal of ACA and the cutting of Medicaid down to size. As Avik Roy points out, Medicare cannot be ignored for long. Nor should the cancer of employer health insurance. The same sound conservative logic points inexorably to its abolition.

The loss of freedom is on a positively Soviet scale. Consider these well-known facts.

  • Employer health insurance covers the healthy and the unhealthy alike, and at the same rates. That’s totally unjust. Why should a 25-year-old trainee who runs a mile every morning, never smokes or drinks, and shops entirely at the farmers’ market, hand over part of her hard-earned pay to subsidise the asthmatic 55-year-old chappie in Accounts who smokes, drinks, never takes any exercise and alternates between McDonalds, KFC and Dominos for his daily injection of cholesterol-, sugar-, and additive-laden food? It’s positively un-American, and removes the vital incentive to make good lifestyle choices.
  • Male employees have as much deducted from their pay as women, and the single as much as those who have children. Nothing wrong with children of course, but it’s a personal choice just like preferring a new car to a holiday in Tahiti, and people should assume the consequences of their actions. If a woman has a child without previously arranging for a husband, that is likewise her lookout.
  • Employer health insurance is a form of bondage that ties the employee to her employer independently of the mutual benefit of a free labour contract. The costs of losing a job include, as they do not in America’s competitors, the loss of health insurance. Many American workers are trapped in jobs they are not suited for, or have gone sour on, through this fear.
  • Employers are also faced with a heavy cost their competitors in other countries do not bear. In a world without employer health insurance, cash wages go up of course. But the employer would still gain on balance: from not keeping on the unhappy workers whose main motive for staying on is assured health cover, and the high administrative costs of running the scheme. Danish businesses don’t employ a team of people in Human Resources to look after employee health, what would be the point?
  • The public policy win comes from bringing back that vital “skin in the game” when individuals buy insurance for themselves. In employee health insurance, it’s not so much a principal-agent problem as the absence of an identifiable principal. Firms know little about health insurance. They buy it because it’s expected by new hires and valued long-serving core staff alike, and everybody else does. They will buy “good enough” and then stop looking. Unleashing the power of the free market to lower prices implies real competition in every sale. This means each individual or family unit must be an agent in a vigorously contested market.

Employer health insurance must go, with the massive tax break transferred to individuals. Some of my more radical libertarian friends think that’s far from enough. All insurance is morally flawed, as it removes the “skin in the game” by spreading risk across large pools. Insurance breeds carelessness. Beyond that, the whole concept of employer and employee is suspect. The Marxists are right, they say, in condemning the wage relationship as servile and alienating: you are not selling something you have made to another, but selling him your very will, accepting a temporary but still abject bondage under which your master controls what you do. In a truly free society, the only employees are women and children naturally subject to the authority of the male head of the family. Should slavery be reintroduced, an idea on which I offer no opinion, it would complete the salutary restoration of the Roman paterfamilias.

We must reluctantly postpone these fascinating debates to another day. For now, Republicans must use their possibly short-lived control in Congress to strike off the tentacles of employer health insurance slowly strangling American business and American freedom.

The “American Employee Freedom in Health Care Act” would be very short. It only needs two operative articles, leaving aside the changes to the tax code.

Article 1. With effect from 1 January 2019, it shall be prohibited for employers to provide health insurance to employees, under pain of a fine of $5,000 for each employee and year of service for which such insurance is provided.

Article 2. The date of entry into force laid down in Article 1 shall be brought forward to January 1 2018 where the employer is a media organization, registered lobbyist, think tank, political party, or other organization engaging in political advocacy or policy analysis as its principal activity, and the employee is a journalist, columnist, presenter, analyst, or regular commentator.

BCRA will probably kill thousands of Americans every year

…And it’s not alarmist or uncivil to say so.

The effects of insurance on mortality are inherently difficult to precisely forecast.
But we have many strong reasons to believe that uninsuring millions of Americans would cause thousands of them to needlessly die every year.

We can debate the magnitude of this effect and how we might measure it. But the burden of proof does not rest with liberals to defend this sensible proposition, nor to prove that the likely harms associated with BCRA will definitely come to pass. Rather, the burden resides with BCRA supporters to show why we can be confident that snatching coverage from low-income people will not bring serious harm. Bill supporters have not come close to meeting this standard.

At least that’s what I argue in my second piece for Slate.

After Trumpcare, Medicare Part M

Here’s a thought: as soon as we defeat Trumpcare, Democrats in both houses introduce Medicare Part M (for Middle-Aged), covering people ages 50-64.

A. It’s good politics:

1. These are the people who were going to be hit the hardest by Trumpcare premium increases. Offer them a better deal and they’ll support us-and people this age vote!

2. It sounds more moderate than Medicare for All, while also making a solid step closer to single-payer, which the Republicans have managed to make sound like pie-in-the-sky socialism with a side order of end-of-the-world.

B. It’s good policy:

1. These are the sickest people in the Obamacare exchanges-move them out of the pools and premiums go down.

2. BUT they’re healthier than most people now on Medicare: put them into that risk pool and the premiums go down there, too.

DON’T believe Trump when he says Obamacare is collapsing.

DON’T believe pundits who say the Democrats have no platform/positions: this plus increased minimum wage plus let’s get out of Afghanistan is platform a-plenty.