Donald Trump was inevitable. The repeal of Obamacare was inevitable. Six years ago, Neal Gabler explained that in America the Stony-Hearted:
When the political history of the last thirty years is written, scholars will no doubt describe a rightward revolution that jolted this country out of its embrace of New Deal, big-government progressivism and into a love affair with small-government conservatism. But this change, significant as it is, has been undergirded by a less apparent but no less monumental revolution that has transformed the nation’s values, ideals and aspirations. Over those same thirty years, we have become a different country morally from what we were.
We have? Yes, you can make that argument:
The United States has always had a complex national moral system. On the one hand, there is the Puritan-inflected America of rugged individualism, hard work, self-reliance and personal responsibility in which you reap what you sow, God helps those who help themselves, and our highest obligation is to live righteously. These precepts run from Cotton Mather to Ralph Waldo Emerson to Billy Graham.
On the other hand, there is also an America of community, common cause, charity and collective responsibility. In this America, salvation comes from good works, compassion is among the greatest of virtues, and our highest obligation is to help others. These precepts run from Walt Whitman to the late 19th century Social Gospel movement to the Rev. Martin Luther King Jr.
These two moralities managed to coexist – often within the same person – because they were not seen as mutually exclusive, especially in the 20th century. Nor was either the province of one political party or the other. Conservatives could subscribe to the ideals of generosity and compassion, just as liberals could subscribe to hard work and individual responsibility.
Sure, but that was then and this is now:
Liberals have come to see the emphasis on the individual and self-reliance as a form of civic irresponsibility and selfishness – a way to justify rogue economic behavior and enrichment at the expense of the community. It was, incidentally, a charge adherents of the novelist Ayn Rand gladly invited because they believe selfishness is a tough, exalted form of morality. Thus were the moral sides drawn: soft-headed versus tough-minded, big-hearted versus stony-hearted.
And we know who is winning this argument:
Scarcely a generation ago you wouldn’t have found many conservatives who would have sneered at compassion or tolerance or fundamental fairness, even if they disagreed with liberals on how these concepts might operate in the real world. Today, open contempt for these values is conservative boilerplate for Rush Limbaugh, Glenn Beck and Sean Hannity, and even for the Republican Party itself, whose idea of cutting government is always cutting programs that help the weakest and least fortunate Americans and whose idea of compassion is caring about the tax burden of the wealthiest Americans. Beyond politics, these attitudes threaten to make this the first generation that promulgates an individualism untempered by common decency.
Gabler saw that as a problem:
If compassion is seen as softness, tolerance as a kind of promiscuity, community as a leech on individuals and fairness as another word for scheming, we are a harder nation than we used to be, and arguably a less moral one as well.
Or we’re a more moral nation. Paul Ryan still has all his staffers read Ayn Rand. Community is a leech on individuals. As Mitt Romney would have it, that forty-seven percent is leeching off of the good people. That’s a moral statement. Being stony-hearted may be quite moral. It depends on who you ask, and it depends on who’s in charge at the moment.
At the moment, the stony-hearted are in charge, and as Robert Pear and Thomas Kaplan report, the inevitable just happened:
Senate Republicans, who for seven years have promised a repeal of the Affordable Care Act, took a major step on Thursday toward that goal, unveiling a bill to make deep cuts in Medicaid and end the law’s mandate that most Americans have health insurance.
The 142-page bill would create a new system of federal tax credits to help people buy health insurance, while offering states the ability to drop many of the benefits required by the Affordable Care Act, like maternity care, emergency services and mental health treatment.
But the measure landed in rough seas ahead of a vote that Senator Mitch McConnell of Kentucky, the majority leader, wants next week. Four conservative senators, Rand Paul of Kentucky, Ted Cruz of Texas, Mike Lee of Utah and Ron Johnson of Wisconsin, announced that they would oppose it without changes – more than enough to bring it down.
“It does not appear this draft as written will accomplish the most important promise that we made to Americans: to repeal Obamacare and lower their health care costs,” the four wrote in a joint statement.
The bill wasn’t stony-hearted enough for them, but there were those who whose hearts were not yet stone:
Other Republican senators, like Dean Heller of Nevada and Rob Portman of Ohio, expressed their own qualms, as did AARP, the American Hospital Association, the American Cancer Society Cancer Action Network and the Association of American Medical Colleges.
“We are extremely disappointed by the Senate bill released today,” the medical school association wrote. “Despite promises to the contrary, it will leave millions of people without health coverage, and others with only bare-bones plans that will be insufficient to properly address their needs.”
In fact, this bill could make neither side happy:
Once promised as a top-to-bottom revamp of the health bill passed by the House last month, the Senate bill instead maintains its structure, with modest adjustments. The Senate version is, in some respects, more moderate than the House bill, offering more financial assistance to some lower-income people to help them defray the rapidly rising cost of private health insurance.
But the Senate bill would make subsidies less generous than under current law. It would also lower the annual income limit for receiving subsidies to cover insurance premiums to 350 percent of the poverty level, or about $42,000 for an individual, from 400 percent.
Older people could be disproportionately hurt because they pay more for insurance in general. Both chambers’ bills would allow insurers to charge older people five times as much as younger ones; the limit now is three times.
This is to assure that the (morally) good people get some relief:
The Senate measure, like the House bill, would phase out the extra money that the federal government has provided to states as an incentive to expand eligibility for Medicaid. And like the House bill, it would put the entire Medicaid program on a budget, ending the open-ended entitlement that now exists.
It would also repeal most of the tax increases imposed by the Affordable Care Act to help pay for expanded coverage, in effect handing a broad tax cut to the affluent in a measure that would also slice billions of dollars from Medicaid, a program that serves one in five Americans, not only the poor but also almost two-thirds of people in nursing homes. A capital-gains tax cut for the most affluent Americans would be retroactive to the beginning of this year.
They can do that, because they’re in charge, but there’s still an America of community, common cause, charity and collective responsibility:
Democrats and some insurers say Mr. Trump has sabotaged the Affordable Care Act, in part by threatening to withhold subsidies paid to insurers so they can reduce deductibles and other out-of-pocket costs for millions of low-income people.
And President Barack Obama, who has been hesitant to speak up on political issues since leaving office, waded into the debate on Thursday, saying the Senate proposal showed a “fundamental meanness.”
“The Senate bill, unveiled today, is not a health care bill,” Mr. Obama wrote on his Facebook page. “It’s a massive transfer of wealth from middle-class and poor families to the richest people in America. It hands enormous tax cuts to the rich and to the drug and insurance industries, paid for by cutting health care for everybody else.”
Sorry, but that’s the general idea. That’s how a moral nation deals with leeches, or something. That argument is only implicit, but the whole thing certainly seems mean.
Jordan Weissmann, Slate’s senior business and economics correspondent, assesses the relative meanness here:
Donald Trump called the House GOP’s health care bill “mean.” This one – the Better Care Reconciliation Act – is meaner.
“I thought it wouldn’t be possible for the Senate Republicans to conjure up a bill even worse than that one,” Senate Minority Leader Charles Schumer said at a press conference Thursday afternoon. “Unfortunately, that is what they have done.” He then turned to a red poster with the word “mean” printed across it, and scrawled an “er” in black sharpie next to it. Voilà! “Meaner.”
Corny? Sure. But to Democrats’ credit, it was at least on point.
The Senate version really is more stony-hearted:
Remarkably, the Senate has produced a piece of legislation that would cause even more human wreckage than the much-loathed bill the House passed last month, potentially dealing a historic blow to the American safety net.
The reason why it truly is meaner can be boiled down to another single word: Medicaid. One could maybe argue that the Senate’s bill is mildly gentler to Americans who buy their insurance on the individual market – though even that is debatable. What is indisputable, however, is that the bill sets up Medicaid for even more devastating cuts than what the House contemplated, gradually throttling the program’s funding in order to pay for tax cuts for the wealthy.
In moral terms, the “devil” is in the details:
Many people – including some supposedly ticked-off conservative Republican senators – have already described the Senate bill’s reforms to the individual market as “Obamacare lite.” That’s reasonable enough. Like the Affordable Care Act, the Senate bill would give Americans tax credits to buy health insurance, calculated by their age and income. But these credits would be much stingier.
How much stingier?
Today, under Obamacare, Americans qualify for tax credits if they earn up to 400 percent of the poverty line. Under the Senate bill, the threshold would drop to 350 percent.
Under Obamacare, Americans who receive subsidies have to spend no more than 9.5 percent of their income on premiums. Under the Senate bill, they’d have to spend as much as 16.2 percent.
Under Obamacare, subsidies are designed to help people buy insurance that covers, on average, 70 percent of their health costs. (Those are known as silver plans.) Under the Senate plan, subsidies are designed to buy insurance that covers 58 percent of costs. (Today, that’d be a bronze plan.) Low-income people would get less money to buy crappier insurance with higher deductibles. In other words, their insurance could be all but unusable.
There were, however, some concessions to be kind to the leeches:
While the Senate bill gives people less help to buy coverage, it does avoid some of the truly perverse outcomes for low-income and older Americans that were baked into the House’s legislation, which set its own flat tax credits based mostly on age. For instance, the scheme that Paul Ryan and his colleagues concocted would have left a 64-year-old making $26,500 per year paying more than half his income toward insurance premiums. That same person would be spending closer to 10 percent of his paycheck under the Senate plan.
Unlike the House bill, the Senate wouldn’t let states opt out of Obamacare’s popular consumer protections for patients with pre-existing conditions. Of course, it would still let them ditch other key rules, like the requirements that insurers cover certain benefits, which would make it hard for the sick to find the coverage they need. It would still let carriers charge older patients more than they can now, too. But in terms of regulations, I suppose you could say it is less “mean.”
But that may be all for show:
It’s not clear anybody on the individual market would be much better off than under Obamacare. Fewer would qualify for subsidies, which would be worth less. It’s not clear premiums would fall all that much, especially if states decided to keep the Affordable Care Act’s regulations. Deductibles would be sure to go up. Under the House bill, on the other hand, some middle-class households would probably be eligible for tax credits to buy insurance for the first time. For all the violence that bill would have inflicted on the sick and vulnerable, there were at least a few clear winners. With the Better Care Reconciliation Act, not so much.
But the individual market is a bit of a sideshow. It’s where around 22 million people get their health insurance today. The real issue is Medicaid – which covers about 62 million individuals, or almost one-fifth of Americans, and 39 percent of children. Both the House and Senate would make historic, devastating changes to the program that would leave millions uninsured. But the Senate’s are more extreme. Where Paul Ryan would take a hatchet to Medicaid, Mitch McConnell would break out the Black & Decker.
Again, details matter:
Both bills would roll back Obamacare’s Medicaid expansion. The Senate would go about it more slowly – a big priority of the chamber’s moderates, who supposedly didn’t want to “pull the rug out” from anybody – but the end result is the same. Both bills would also cap federal Medicaid spending for the first time, giving each state a fixed chunk of change each year to help pay for each enrollee. But after 2024, the Senate bill would increase that funding much more slowly by tying it to a lower measure of inflation. That tiny, technical-sounding change would cause Medicaid’s purchasing power to rapidly wither.
To be specific: The House bill would increase Medicaid funding based on the medical component of the Consumer Price Index. (Spending for some groups, like the elderly and disabled, would be based on the M-CPI plus 1 percent.) This sounds reasonable, until you realize that the M-CPI, as it’s called, mostly tracks items that families pay for out of pocket – glasses and Tylenol rather than hip-replacement surgery. Hitching Medicaid to the index would drag the program’s budget growth, making it nearly impossible for states to continue offering enrollees the same level of care they receive today. Statehouses would be forced to choose between reducing the number of services Medicaid covers, reducing payments to doctors, or even cutting the program’s rolls.
The Senate prefers an even more severe approach. After 2024, it would adjust Medicaid based on the normal Consumer Price Index, which tracks things like food, clothing, and electronics, trailing far behind medical inflation. There is no real policy justification for this other than budget-cutting.
That’s just plain mean:
How bad could the damage be? Well, the House bill would have slashed about a quarter of Medicaid’s future funding over a decade. The Senate plan cuts much deeper. Over time, this approach could easily drain hundreds of billions more from Medicaid, leaving the program a shadow of its former self as its budget fails to keep up with ever-climbing costs.
Medicaid is bedrock piece of the American health care system, larger by enrollment than Medicare. Both the House and Senate would cut it back. Either approach would signal a generational disaster for the American welfare state. But Mitch McConnell’s bill would bring on the travesty even more quickly. So, yeah, you could say his bill is meaner.
Or his bill is more moral in the Ayn Rand sense. Take your pick, or as Katy Waldman argues, stop using that word:
When Trump used the word mean, it seemed at once inadequate and innocent – a plaintive plea from the mouth of a babe. The president’s moral imagination is a Chinese violin with only two strings: nice and mean. The House bill plucked the second one.
When Schumer used the comparative meaner, it seemed full of foolishness. The Democrats were so absorbed in and amused by their lame performance of outrage that they turned genuine moral indignation into kindergarten-grade insult comedy. That bill was mean. This bill is mean-ER. We’ve got your votes, amirite?
Okay, don’t use that word. Talk substance. That’s what Daniel Gross does here:
One of the expressed intentions of Republicans’ efforts to repeal and replace Obamacare is to undo some of the age-related distribution inherent in the system. Today, healthy young people pay more so that older, less-healthy people don’t have to pay quite as much.
The idea was to reverse that, to be fair to healthy young people, but that ignores real life:
Asking older people to pay so much for health care is particularly devastating given the ongoing structural changes in our economy. Most Americans don’t make that much money. The median household income in the U.S. is about $55,000. But the median household income for those in the 55–64 cohort is markedly below the median for those in the 45–54 and 35–44 cohorts. Most Americans don’t have much savings. The median retirement savings for people between the ages of 50 and 55 in 2013 was $8,000.
Now, the best way to avoid paying a large chunk of your income and savings for insurance for a few years until Medicare kicks in at 65 is to keep a payroll job with health insurance. But increasingly, American employers don’t want to keep people in their 50s on their payrolls. The closer Americans get to Medicare eligibility, they more likely they are to be pushed out of their jobs – and out of the workforce entirely. The data from the Bureau of Labor Statistics tells the tale. In 2014, 79.6 percent of Americans between the ages of 45 and 54 were in the workforce. But of those between the ages of 55 and 59, 71.4 percent were in the workforce, while 67 percent of those aged 60–61 were and just 53 percent of those between 62 and 64 were.
In virtually every industry, at virtually every level of the income ladder, employees are explicitly seeking to move people off the payroll as they age into their 50s. Which means more of those Americans must buy insurance on the market the Republicans are currently trying to remake.
That may be so, but to some, that doesn’t matter:
Given the relentless global competition and pressure continually to boost profits, it is likely that this dynamic will intensify in coming years. Which should push reasonable policymakers to make it easier for older people to afford health insurance on their own, either by maintaining existing premium support, or by, say, opening up Medicare to people over the age of 50. But of course, the Republican plans are going in precisely in the opposite direction.
Everyone knows this, and what the Republicans are up to is massively unpopular – only sixteen percent of Americans said the House bill was a good idea, including only a third of Republicans, and the Senate bill will be even more unpopular. Why do this? Jamelle Bouie suggests this:
The Republican health care bill doesn’t solve any urgent problem in the health care market, nor does it represent any coherent vision for the health care system; it is a hodgepodge of cuts and compromises, designed to pass a GOP Congress more than anything. It is policy without any actual policy. At most, it exists to fulfill a promise to “repeal Obamacare” and cut taxes.
Perhaps that’s enough to explain the zeal to pass the bill. Republicans made a promise, and there are forces within the party – from hyper-ideological lawmakers and conservative activists to right-wing media and Republican base voters – pushing them toward this conclusion. When coupled with the broad Republican hostility to downward redistribution and the similarly broad commitment to tax cuts, it makes sense that the GOP would continue to pursue this bill despite the likely consequences.
But ultimately it’s not clear the party believes it would face those consequences.
They know better:
The 2018 House map still favors Republicans, and the party is defending far fewer Senate seats than Democrats. Aggressively gerrymandered districts provide another layer of defense, as does voter suppression, and the avalanche of spending from outside groups. Americans might be hurt and outraged by the effects of the AHCA, but those barriers blunt the electoral impact.
The grounds for political combat seem to have changed as well. If recent special elections are any indication – where GOP candidates refused to comment on signature GOP policies – extreme polarization means Republicans can mobilize supporters without being forced to talk about or account for their actual actions. Identity, for many voters, matters more than their pocketbooks. Republicans simply need to signal their disdain – even hatred – for their opponents, political or otherwise. Why worry about the consequences of your policies when you can preclude defeat by changing the ground rules of elections, spending vast sums, and stoking cultural resentment?
Bouie suggests they’re doing this because they can. And who is going to stop them?
It won’t be these people:
Chaos erupted outside the office of Sen. Mitch McConnell (R-Ky.) Thursday, shortly after Republican leaders unveiled their closely guarded plan to repeal and replace the Affordable Care Act.
Capitol police were seen physically removing demonstrators, many of whom were in wheelchairs and holding medical equipment, as they chanted their disapproval of the draft legislation.
“No cuts to Medicaid,” they said, while blocking hallway access from McConnell’s office.
The protest was reportedly organized by the group ADAPT, an advocacy organization for people with disabilities. Images and video recordings of the scene quickly circulated on social media…
While the dramatic scene unfolded, Democratic senators led by Minority Leader Chuck Schumer (D-NY) blasted the bill as “heartless” and a “wolf in sheep’s clothing.”
Republicans shrugged. These were “defective” useless people after all, the leeches, although no Republican dared say that. That’s what Rush Limbaugh and conservative talk radio is for. Still there is an America of community, common cause, charity and collective responsibility:
Sen. Elizabeth Warren (D-MA) ripped into Senate Republicans’ Obamacare repeal bill on Thursday, saying the proposal would pay for tax cuts for wealthy Americans with “blood money” that comes from cutting essential services for the poor, including Medicaid.
“It is finally clear how the Republicans were spending their time locked in those back rooms,” Warren said from the Senate floor, referring to a weeks-long secretive, GOP-only drafting process. “Now we know the truth.”
“Senate Republicans weren’t making the House bill better,” Warren continued. “Nope, not one bit. Instead they were sitting around a conference room table dreaming up even meaner ways to kick dirt in the face of American people and take away their health insurance.”
She did let it rip:
“Medicaid is the program in this country that provides health insurance to one in five Americans, to 30 million kids, to nearly two out of every three people in a nursing home. These cuts are blood money. People will die. Let’s be very clear. Senate Republicans are paying for tax cuts for the wealthy with American lives.”
She launched into examples of Americans affected by the cuts to Medicaid, including a senior living at home who would be unable to afford the help she needs to avoid moving into a nursing home, and a child born too early whose parents risk homelessness to pay for his care.
“Senate Republicans can wave their hands and say that everyone will be fine, but it is time for the rest of us to take a long, hard look at exactly what would happen to the people who have to live with the Republicans’ reckless cuts,” she said. “Senate Republicans know exactly what they are doing with this health care bill. Their values are on full display. If they want to trade the health insurance of millions of Americans for tax cuts for the rich, they better be ready for a fight. Because now that this shameful bill is out in the open, that’s exactly what they’re going to get.”
That’s the moral argument. She’s not Ayn Rand. Ayn Rand is dead. Elizabeth Warren is alive and kicking, and kicking back.
That must trouble Republicans, and Kevin Drum tells a curious personal story:
My mother grew up in a Republican family. When Herbert Hoover was on the radio, everyone listened. But later she became a Democrat. What happened?
Well, she went off to college. But not some bleeding heart lefty bastion. She went to USC, which was even more Republican in 1950 than it is now. She didn’t get indoctrinated by a bunch of fuzzy liberal professors.
So what caused the switch? I asked her once, and she said that during her college years she came to the conclusion that Republicans were just mean. So she became a Democrat.
This struck me because I’ve long used the exact same word in the privacy of my own thoughts. I can write a sophisticated critique of conservative ideology as well as the next guy, but the truth is that it mostly boils down to a gut feel that Republicans are mean. I’ve never said this out loud because it sounds so kindergarten-y, but there it is. I think Republicans are mean, just like my mother did.
But now our time has come. Donald Trump started it, with his contention that Paul Ryan’s health care bill was “mean.” Today, Barack Obama picked up the ball, writing on Facebook about the “fundamental meanness at the core of this legislation.” And then Chuck Schumer weighed in with a big red poster calling the Senate health care bill “meaner.”
So that’s that. It’s now okay to ditch the ten-dollar words and just spit it out. Republicans are mean.
Neal Gabler called that individualism untempered by common decency, but sometimes short words are better than long words. Not that it matters – everyone knows who’s in charge at the moment – for now.