Health Care, Medicaid, Politics, Trump

Who Knew It Could Be So Complicated…

“More than a third of Americans believe that Medicaid is akin to welfare, with the implicit subtext that racial and ethnic minorities are the principal beneficiaries.

“If that’s what they think, they’re dead wrong.”

Thomas Edsall, writing in the New York Times

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“Nobody knew that health care could be so complicated,” the president of the United States said a while back. And he said that after promising during the last campaign that every American would have health care coverage and that the wallet impact of paying for health insurance will be a “lot less expensive” for everyone – taxpayers, consumers and providers. Who knew?

All that bluster and ignorance amounted to a pipe dream then and it remains a cruel joke now as Senate Majority Leader Mitch McConnell madly maneuvers to “repeal and replace” Obamacare with almost no regard for the wide swath of damage his legislation will inflict on millions of Americans. The Congressional Budget Office projects 22 million Americans will lose health insurance if the GOP plan is adopted.

The President Meets with GOP Senators on Health Care legislation

That the Republican health care plan is almost completely disconnected from reality should be no great surprise. Republicans have been making political hay out of trashing Barack Obama’s signature legislative initiative for eight years, while never proposing any rational plan to replace what they succeeded in convincing their political base was nothing short of a socialist plot. It was a ruse. A big con.

Pennsylvania Republican Senator Pat Toomey provided a textbook example of a Washington political gaffe – defined as what happens when a politician stumbles and speaks the truth. “Look, I didn’t expect Donald Trump to win,” Toomey told voters this week. “I think most of my colleagues didn’t, so we didn’t expect to be in this situation.” In other words, demonizing the other party’s health care approach was really all about politics never about policy.

History will record, even if few Republicans acknowledge the fact, that the broad outlines of Obama’s Affordable Care Act were once the basis of conservative health care policy. I know its old news, but a guy named Mitt Romney implemented essentially the same policies as governor of Massachusetts and then spent the 2012 election trying to deny he had ever heard of the coverage mandate. But, admittedly that was way back when conservatives actually cared about policy. Or cared about something as basic as trying to get as many Americans as possible insured against the vagaries  we all face regarding health and wellness.

Romneycare before Obamacare

Just a reminder: For health insurance to work, both in terms of actuarial soundness and individual affordability, you need to have the greatest possible number of people covered by an insurance plan. The whole idea of insurance is to spread the risk, flatten out the cost to everyone and control costs both for consumers and providers of care. This is why every state in the nation mandates that when you license your automobile you must provide proof of insurance. We don’t allow an individual motorist to avoid coverage that serves to protect their interest as well as the interests of the rest of us simply because some yahoo in a pick-up truck hates a “government mandate.” You either buy the auto insurance or you don’t drive, at least not legally.

Insurance isn’t about “freedom” to chose. It is about sharing risk and spreading cost. It is a responsible we are all in this together way to broadly address a greater public good, which is why the ACA mandated coverage and provided subsidies for the millions of Americans who would otherwise be priced out of the insurance market. At the same time, Obama’s health insurance plan expanded the existing government program called Medicaid in order to address the needs of millions of Americans – including many, many children – struggling to make ends meet on low incomes, living with disabilities or closing out their days in a nursing home.

The End of Medicaid as We Know It…

The legislation Republicans are attempting to advance in Washington, D.C. would end the individual mandate requirement and dramatically reduce the national commitment to Medicaid to the tune of $750 billion over the next decade.

As Thomas Edsall wrote recently in the New York Times, “Since its inception in 1965, Medicaid has become an integral and major part of the American safety net. Not only does it cover health care for the poor, it prevents millions of members of the working and middle classes from losing all their savings and falling into bankruptcy when they or their family members become too old, sick or disabled to work. Medicaid also provides essential help in family planning, preventing premature births and supporting infant and child health.”

Edsall correctly notes that a significant majority of Medicaid beneficiaries are the very people who elected Donald J. Trump last year and gave Republicans control of Congress. “In McConnell’s Kentucky,” Edsall wrote, a recent Georgetown University “study found that Medicaid has become a crucial source of coverage for adults. Before the passage of Obamacare in 2010, 13 percent of adult Kentuckians were covered; after passage, in 2013-14, the percentage more than doubled to 28 percent. Over the same period, the percentage of uninsured adults in Kentucky fell from 26 to 10 percent.”

The dog’s breakfast that is the GOP health insurance plan is in the sorry shape it’s in – polling indicates a tiny fraction of Americans support it – because Republicans have, despite what House Speaker Paul Ryan might contend, abandoned real policy for almost any mishmash of gobbledygook that seems to resemble a “fix” to Obamacare. So desperate are Republicans to have a political “win” that they willfully misrepresent what their proposals will accomplish, a strategy that increasingly appears to have caught up with them back home. With this approach – say pretty much anything and hope to get past the 2018 mid-terms – McConnell and Company have essentially embraced a Trump strategy – promise big change, fudge (or lie) about the details and hope against hope that the entire spectacle will make numb all but the most ardent and partisan believers.

It Will be Great, But If It Isn’t That’s OK…

One of the rich stories of the recent charade involved a made-for-television meeting at the White House where Trump invited all 52 Senate Republicans downtown for a chat about health care legislation. Trump, positioned with two of the most skeptical senators – Susan Collins of Maine and Lisa Murkowski of Alaska – on either side of him, promised that a great, great bill would emerge from McConnell’s log rolling. Then he stepped all over that message by suggesting that if it all fell apart, well, that would be all right, too.

As the Times reported in a story that Trump immediately decried as “fake news,” one supportive senator “left the meeting at the White House with a sense that the president did not have a grasp of some basic elements of the Senate plan—and seemed especially confused when a moderate Republican complained that opponents of the bill would cast it as a massive tax break for the wealthy.”

But, of course, the president displays next to no interest in the complicated, life-and-death details involved in these issues and is in fact almost certainly unable, thanks to intellect and disposition, to learn anything that might help fashion a path forward. He reportedly told lawmakers earlier this year that they should focus on the “big picture” and “forget about the little shit.” Essentially that is what Republicans have been doing for eight years.

Over the last eight years Democrats made a fundamental political mistake by never adequately and compellingly explaining what they were attempting to accomplish with the Affordable Care Act. There was no clear message from supporters of the Act beyond wanting to bring down the number of uninsured Americans. Little sustained effort was made to explain why more people being covered meant a better system and Democrats compounded their message mismanagement when they made Faustian bargains with drug and device manufacturers in order to pass legislation. Those bargains have clearly exacerbated the job of controlling costs.

Republicans filled this muddled communication void, filled it for years, by employing much of the same rhetoric they have been using since the American Medical Association opposed Harry Truman’s national health care plans in the 1940s.

The Republican message can be summed up succulently, if incorrectly: Democrats were putting us on the road to socialism. What American health care required, Republicans said again and again, was more competition. “We’ve got to do something to reinject free-market forces into this environment,” Utah Senator Mike Lee said recently on CBS’s Face the Nation. “If we can bring free-market forces to bear, we can bring down costs for middle Americans.”

Utah Senator Mike Lee

That is, of course, another pipe dream and ignores the way the American system of health care actually works. Republicans seem to embrace, to paraphrase John Maynard Keynes, a health care economy that they wish existed rather than the one that actually does exist.

The “free-market” celebrated by Lee, Senator Ted Cruz and others actually serves as a major driver of the constant increases in health care costs. The American reliance on a fee for service market system provides outsized financial rewards to Big Pharma, specialty docs, many insurance companies and hospitals – including hospital CEO’s – even those who continue to claim they operate as not for profit organizations.

Vice President Mike Pence recently touted the “market based” system as the country’s only solution to a broken health care system, while in reality it is a major cause of the American health care mess. Pence and many embracing the market ignore all the vast data that proves the American system with its wacky incentives and general lack of accountability is wildly more expensive and delivers worse results than any county in the rest of the developed world.

Data compiled by the Organization for Economic Co-operation and Development, for example, shows that “the United States spends close to 20 percent of its gross domestic product on health care, nearly $10,000 per person [annually], roughly twice as much as countries like Britain, which has a nationalized health service. Americans, as a whole, pay more to get less.”

Costs More, Produces Less…

In an important new book on what’s wrong with American health care Elisabeth Rosenthal, the editor-in-chief of Kaiser Health News made an observation that most of us can identify with.

“Who among us,” Rosenthal writes in An American Sickness: How Healthcare Became Big Business and How You Can Take It Back, “hasn’t opened a medical bill or an explanation of benefits statement and stared in disbelief at terrifying numbers? Who hasn’t puzzled over an insurance policy’s rules of copayments, deductibles, ‘in-network’ and ‘out-of-network’ payments—only to surrender in frustration and write a check, perhaps under threat of collection?”

Rosenthal argues that the health care market simply doesn’t work the way Home Depot or Safeway works.

“More competitors vying for business doesn’t mean better prices; it can drive prices up, not down…. Economies of scale don’t translate to lower prices. With their market power, big providers can simply demand more…. Prices will rise to whatever the market will bear.”

As the New York Review of Books noted in a recent review of the book: “Rosenthal’s indictment extends well beyond insurance companies. She looks carefully at hospitals, and the reader learns how they have been transformed by marketing consultants and administrators with business degrees to generate large profits, though many still enjoy a tax-exempt status as ‘nonprofit institutions’—meaning that they pay ‘almost no US property or payroll taxes.’ Instead of profit, tax-exempt hospitals call it ‘operating surplus.’ In 2011, the US government calculated that hospitals were getting an annual tax advantage of $24.6 billion. Steven Brill, who highlighted the predatory pricing that occurs in calculating costs of care in America’s Bitter Pill (2015), recently listed the yearly pay of the CEOs of large hospital systems, which often amounts to many millions of dollars. Rosenthal points out that ‘total cash compensation for hospital CEOs grew an average of 24 percent from 2011 to 2012 alone.’”

Both parties – but Republicans more than Democrats – have over promised and under delivered on the matter of health care insurance. But now the GOP faces the stark reality that the dozens of votes to “repeal” Obamacare were, as Senator Toomey has now admitted, just so much political rhetoric designed to gin up confused consumers and build a partisan advantage in Congress. Republicans have never had anything like a “replacement” for the Affordable Care Act and that policy failure is now wrapped around Mitch McConnell like one of those flimsy hospital gowns with the ties in the back. Anyone who has donned one of those garments knows it doesn’t cover much. Now the majority leader’s inadequacies are all too visible.

Fact Free, Hyper-Partisan…

The debate over health insurance policy has tripped into the same fact free zone of hyper-partisanship that dominates virtually every public policy discussion these days. Yet, the real news for millions of Americans is both obvious and frightening. Millions of Americans are still without health insurance and Republican plans will only make things worse, with many folks just a paycheck or two away from economic disaster.

The “system” is hugely inefficient and rewards many of the wrong things such as paying providers for performing procedures rather than improving health. Costs for everything from a hospital stay to a blood test are often widely out of whack with what the service actually costs. Primary care doctors are overworked and under loved, while the local orthopedic surgeon – you can look it up – is doing very, very well thank you.

I have long felt that the mess of policy known as Obamacare was ironically both a political loser for Democrats and a vehicle to move health care policy in a better direction. In a real working political system, unlike our broken system, lawmakers would keep the best features – an insurance mandate that provides basic coverage centered on preventive care, for example – and work to put in place real incentives that actually bend the cost curve and improve affordability. But such pragmatism is another pipe dream and in the current political environment nearly impossible to contemplate.

It has also been clear to me that the ultimate “fix” for American health care will eventually lead to what exists in most of the rest of the western world – a single payer system that some have started to call “Medicare for All.”

It is generally the American way of politics to gradually chip away at the margins of a problem hoping to slowly, incrementally change things for the better. This approach has given us Obamacare as well as Mitch McConnell’s approach and left us with the most expensive health care in the world and some very marginal outcomes. This truly is not sustainable.

Better to vastly simplify the system with a program that covers basic and preventive care, regulates expensive medical procedures and drug costs the way we regulate public utilities and let insurance companies figure out how to offer gold plated supplemental plans for those who can afford them. We certainly have enough money in our health care “system” to do these things. What we have is problem of how the money is allocated across the health care landscape and, of course, we have a surplus of partisan political posturing that makes real solutions nearly impossible to craft.

This much is true: whatever happens with Republican plans to “repeal and replace” what Barack Obama helped create, the GOP will own the fallout for what comes next. It is not a huge surprise, in fact it’s quite obvious, that both parties have an interest in fashioning health care policy that insures coverage for millions, reduces costs and improves outcomes. The problem is that not enough people in either party are willing to admit the obvious.

GOP, Health Care, Medicaid, Trump

The Art of the Miscalculation

“Hello, Bob. So, we just pulled it.”

        Donald J. Trump phones Washington Post reporter Robert Costa to report on the art of his failed deal.

————

Congressional Republicans spent seven years – and 60-plus repeal votes in the House of Representatives – promising their most fervent supporters that if they ever got all the political power in Washington, D.C. they would wipe away the hated Obamacare on Day One.

On Day Sixty-four they ran head long into an old political reality – don’t believe your own press releases.

What could go wrong?

In the end, the collapse of the Republican plan to “repeal and replace” Barack Obama’s signature legislative accomplishment – the Affordable Care Act – was based on a huge miscalculation, a miscalculation that is now the signature reality of the Grand Old Party. The politics of opposition met the realism of substance. Given seven years to come up with a genuine alternative to what virtually everyone concedes is a flawed national health policy, Republicans, particularly the vacuous leader of their party, punted on substance.

Just consider what President-elect Trump told the Washington Post a week before taking office. “We’re going to have insurance for everybody,” Trump said. “There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.” People covered under the law, he said, “can expect to have great health care. It will be in a much simplified form. Much less expensive and much better.”

Perhaps even he can’t spin this one…

The Post’s Robert Costa and Amy Goldstein reported in that January interview that Trump – wait for it – declined to discuss specifics. Big surprise. There were no specifics short of a massive tax cut for the most well to do and a butchering of Medicaid.

The intellectual bankruptcy of Donald Trump’s GOP, the total triumph of puffy rhetoric over hard reality, was on full display during the Republican art of the fail. The empty suit in the Oval Office met the empty heads in Congress. Of course, Trump predictably blamed Democrats for failing to undo the legislation that they bled over and that cost the party many seats in Congress. It won’t wash. Democrats actually believe in what they have done, while Republicans now fully embrace the smoke and mirrors that surround Trump and the party he now owns, if cannot control. Not surprisingly the post mortem’s have been, and brutally so, all about Trump’s failure and that of the once and never again policy wonk Paul Ryan.

“It’s hard to overstate the magnitude of the Day 64 defeat,” wrote Axios’ Mike Allen, a D.C. access journalist who rarely misses a chance to curry favor with the powerful. “President Trump, who made repeal-and-replace a central theme of his campaign, and House Republicans, who made it the central theme of every campaign since 2010, lost in a publicly humiliating way despite controlling every branch of government and enjoying margins in the House rarely seen in the past century.”

The Miami Herald – Trump won Florida just four months ago you may recall – was just as critical. Republicans “made a huge political miscalculation,” the Herald’s editorial said. “They were vociferous. They were resolute. Ultimately, they were clueless. Well, their constituents, many getting preventive care for the first time, or prenatal care, or cancer treatments clued them in: Obamacare, for all its faults, was working for them.

“Ryan finally — finally — stated the obvious: ‘Doing big things is hard.’ (We’re suppressing a ‘Duh!’) And it’s especially difficult when you leave out preparation and inclusiveness to meet a long-touted promise.

And it hasn’t just been the “opposition” press delivering harsh judgments about the Republican debacle. Right wing websites savaged Congressional Republicans with The Drudge Report featuring a photo of the German airship Hindenburg bursting into flames over the headline: Republican Catastrophe.

Republican Catastrophe (Photo by Sam Shere/Getty Images)

Politico’s Tim Alberta relayed this little bit of color from a critical meeting Trump had last Thursday with the self-righteous egotists of the hard right House Freedom Caucus. “Forget about the little shit,” Trump told those who taught the new president his painful lesson about the art of the Washington deal. “Let’s focus on the big picture here,” the Closer-in-Chief opined. Trump’s message, of course, was that substance doesn’t matter. Don’t sweat the details. The art of the flim-flam got him elected, after all. Who would have thought governing could be so hard?

Trump’s constant use of shape shifting lies notwithstanding, Republicans own this colossal mess and for one principle reason: they have abandoned governing, which is to say substance, in favor of once again trotting out the old hackneyed rightwing clichés and policy inconsistency. Trump’s promise of “health care for all” that would lower costs was always nonsense and internally inconsistent, about as intellectually honest as a sales pitch for Trump University.

This defeat was so big and so obvious that perhaps even Donald Trump can’t spin it away. And Congressional Republicans are going to have difficulty escaping the reality that they fumed against Obamacare for seven politically productive years, but when given a real chance to change the law – or repeal it outright – the GOP quarterbacks took a knee.

Stipulate the obvious: Obamacare has problems. Premiums are too high for many working poor, some states have opted out of the Medicaid portion of the program and the whole scheme remains complicated and confusing. Blame Democrats for some of the confusion. They have never been able to articulate a consistent message about the benefits and there have been real benefits, including insurance coverage for millions of Americans who had not been covered before. Also blame Republicans for the confusion because they have repeatedly misrepresented the negatives impacts of a program that impacts less than 10% of the entire health care marketplace.

Still, Obamacare needs work just like the defense budget or Trump’s golf game needs work, but the constant GOP mantra that the Affordable Care Act is imploding or cratering the economy is just as nonsensical as the tweets from the West Wing. But having ridden the “Obamacare is killing America” hobby horse to electoral success Republicans, as the New York Times pointed out, went searching for a solution to a problem they invented. The problem was invented, of course, because of a burning desire to continue to exploit the issue politically rather than actually work to improve health care. The approach clearly worked. What was missing, as the Times noted, was a “coherent idea or shared vision of what [Republicans] want to achieve and what problem they mean to solve.”

The one and never again policy wonk. (AP Photo/J. Scott Applewhite)

As one wag noted Republicans might have had a better chance to push their plan if they could have pointed to any place in the world were their ideas about enhancing “competition” in health care is working. Americans pay more, have worse outcomes and see more of their fellow citizen’s uninsured than any other major industrialized country. And no country does health care the way we do. The Republican approach wasn’t in any way a fix for a still fractured American approach to health care, but instead would have doubled down on the only strategy the GOP has known in the last two decades: cut taxes for the wealthiest and tell the poor to get a job.

Obama, in pushing the legislation in 2009, sought to reduce the number of uninsured and encourage more preventive care. He succeeded and would have succeeded even more broadly had Republicans not spent every day of both his terms attempting to delegitimize his presidency and with it his legislation. When Republicans got their chance to show the country what they value – should I mention they have more control over the government than they have enjoyed since the 1920s – they opted to advance a plan that would have ended coverage for 24 million Americans over the next decade and gutted the Medicaid safety net for many of the same working class Americans who, against their own best interests, put Donald Trump in the White House.

To the moral bankruptcy that has accompanied the Congressional Republican embrace of the very idea of Donald Trump as their leader, now you may add the intellectual bankruptcy of treating actual governance the way Trump treats the presidency – with contempt and arrogance.

The Atlantic’s Russell Berman had one of the best summaries of the Republican health care fiasco and one of the best quotes. “I’ve been in this job eight years,” Republican Representative Tom Rooney of Florida told Berman, “and I’m wracking my brain to think of one thing our party has done that’s been something positive, that’s been something other than stopping something else from happening. We need to start having victories as a party. And if we can’t, then it’s hard to justify why we should be back here.”

Now, that is a perceptive politician.

Cenarrusa, Idaho, Journalism, Medicaid

Sorry, Wrong Number…Many, Many Times

My Dad used to smile when telling his story about the young fellow who had just seen the classic 1962 World War II movie – The Longest Day – about the D-Day invasion of France in 1944 and was, in turn, telling his own father about the film.

The old man listens patiently and then off-handedly tells his son, “I haven’t seen the movie, but I was there for the play.”

In the same spirit as that old story, I have not seen the 1948 Barbara Stanwyck/Burt Lancaster movie – Sorry, Wrong Number – but I have definitely been living the play. My play is called: Trying to Reach Health and Welfare? Sorry, Wrong Number.

There is nothing special or particularly unique about my telephone number except that the first seven digits of my number match the first seven digits of a toll-free, helpline number – Medicaid Automated Customer Service – managed by the Idaho Department of Health and Welfare. I know this rather obscure fact because I have been averaging two or three “Health and Welfare calls” every weekday for the last two years or so. I long ago lost track of the number of calls, but it beyond hundreds and into the thousands. Thankfully, callers with questions about their Medicaid benefits must assume no state employee works on the weekend, so my phone tends to get the weekend off, as well.

Months ago I thought I had identified the answer to all these wayward calls, but alas it was a fix without a cure. On the state government website that promotes the toll-free number the “1” before the toll-free number had been, inexplicably, left off the rest of the number. So an unsuspecting caller, say from Weiser or Bonners Ferry – I’ve had calls from every corner of the big state of Idaho – would just dial the number shown (minus the “1”) and get me. I called a helpful state agent and asked if maybe, just maybe they could add the “1” and solve the problem of the call from Mrs. Jones from Caldwell, she needs to talk about her niece’s Medicaid needs, ending up on my voice mail. Problem solved, right? Not so fast. The wrong numbers declined a bit, but did not end. I have to assume regular callers to the toll-free number have made a note of the non-“1” toll-free number and were still calling, blissfully unaware that some public affairs consultant and part-time blogger was fielding their calls. The voice mail messages on my phone seemed to continue unabated.

So, believing that information is power, I changed the greeting on my phone. No longer was it, “You have reached me and I can’t take your call right now…” My message became much more Medicaid-centric: “If you are trying to reach the Department of Health and Welfare, you haven’t…hang up and dial a “1” before you call this number.” That’ll fix it, I happily proclaimed, as I began answering questions from people who were really trying to reach me and wondering why I had a Health and Welfare related message on my phone. You can inform some of the people some of the time, but…the calls continue.

I have genuine sympathy for my callers. They need answers to real questions. Judging by some of the hundreds of messages that have been left on my voice mail, many of the callers are confused and uncertain about benefits and responsibilities. If you have ever tried dialing into a government agency you know what an intimidating experience it can be. Imagine getting the wrong number and ending up in some civilian’s voice mail, while you worry and wait for a call back. It would be easy to conclude that government just doesn’t work.

My standard procedure now is to try and intercept as many of these calls as I can and re-direct them to a number that begins with that essential “1,” but it is not always possible. And, while I admit that I’ve been annoyed and frustrated by the calls that I get, wasted effort that doesn’t do the callers any good, the “sorry, wrong number” play I’ve been living has given me an entirely new appreciation of what one little glitch in a vast government program can do to create problems and frustrate users.

As Idaho contemplates a major expansion of Medicaid services under the Affordable Care Act – one estimate holds that 100,000 more Idahoans could be covered – and the state’s for profit Medicaid contractor continues to try to make the system work, here’s hoping, and not just for my sake, that they attend to all the details, small and large, involved in an expansion.

And, just for the record, I have equal amounts of sympathy for the state workers who, without much fanfare or appreciation, labor to make an essential program of our society work for people who really need the help. This is a vastly complicated government program, wrapped in layers of regulation and requiring immense levels of accountability. One little digit – that pesky “1” – can frustrate even the most essential government program.

And, yes, I could get a new phone number, but have ruled that out. If Barbara Stanwyck and Burt Lancaster can handle a wayward call, so can I. But, for future reference, do remember that “1” in front of a toll-free number. Given the vast proliferation of telephones these days, it is a given that someone has the number that is toll-free with a “1” and just some schmuck’s voice mail without.

 

 

Baseball, Cuba, Medicaid, Politics

Cuba

Isn’t it Time?

Former President Jimmy Carter and his wife Rosalynn recently made their second trip to Cuba. Carter also went in 2002. Both trips, undertaken as a private citizen (but no former president is really a private citizen), were designed to try and move U.S – Cuba relations in a more positive direction.

Predictably, Carter was immediately denounced as a “shill for Castro” and an apologist for the Cuba government. Such criticism seems to roll of the former president’s back like water off a duck and Carter’s report on the visit, posted at the Carter Center website, paints a much different picture of what he did and said in Havana. Here’s the concluding paragraph of his trip summary:

“Both privately and publicly I continued to call for the end of our economic blockade against the Cuban people, the lifting of all travel, trade, and financial restraints, the release of Alan Gross [a jailed U.S. contractor] and the Cuban Five [Cuban dissidents], an end to U.S. policy that Cuba promotes terrorism, for freedom of speech, assembly, and travel in Cuba, and the establishment of full relations between our two countries. At the airport, Raul [Castro, the Cuba president] told the press, ‘I agree with everything that President Carter said.'”

For 50 years the United States has had an embargo against Cuba. During the Bush Administration and for most of that 50 years, it has been extremely difficult, even illegal, to travel to Cuba. Trade has been strictly banned. The Obama Administration has relaxed the travel rules some, but the chance that the two countries might actually get on a path to more normal relations remains wrapped around the axle of south Florida politics. The Cuba-American community there, largely Republican voters, remains a potent political force and last I checked Florida still played an outsized role in presidential politics. For years the political facts of life in one state have largely dictated the nation’s policy toward Cuba.

Nevertheless, by almost any measure our Cuban policy has run its course, and not just because I’d like to buy an extremely expensive Cuba cigar in the United States. At one time, post-Bay of Pigs and post-Cuban missile crisis it was easy to make the argument that Fidel Castro’s island regime was settling in to become a genuine threat to U.S. and Latin American security. Cuba did meddle in revolutions in far away places, like Angola, but today there is much reason to acknowledge that the Cuba-Soviet relationship was never as seamless as we feared nor was Castro, the socialist revolutionary, as effective as we might have thought. Cuba’s economy struggles today and the embargo, rather than bringing down Castro, has hurt the Cuban people and given the regime its anti-American reason d’etre.

Here’s the analogy that works for me. We’ve had 50 years of deadlock and non-engagement with Cuba, a country 90 miles from our shores, while halfway around the world, thanks originally to Nixon and Kissinger, we have engaged the Chinese and, I would argue, slowly, but steadily, helped bring a measure of the free market and openness in that communist country. We may have gone too far. The Chinese now threaten our economic leadership in the world. At the same time, we engage Vietnam, a country in which we fought a long and bloody war, with trade and diplomacy. We have an unsteady, but absolutely necessary relationship with Putin, the old KGB chief, in Russia. But nothing of any substance with Cuba.

Idaho and other Pacific Northwest conservatives, guys like Sen. Mike Crapo and Gov. Butch Otter, have long pushed for more trade opportunities with Cuba, the Castro brothers notwithstanding. In February 2008, Crapo signed a bipartisan letter to the Bush Administration, asking for a rethinking of U.S. policy in light of the resignation of Fidel Castro.

“Our current policy deprives the United States of influence in Cuba,” Crapo wrote, “including the opportunity to promote principles that advance democracy, human rights, and the rule of law.  By restricting the ability of Americans to travel freely to Cuba, we limit contact and communication on the part of families, civil society, and government.  Likewise, by restricting the ability of our farmers, ranchers, and businesses to trade with Cuba, the United States has made itself irrelevant in Cuba’s growing economy, allowing Cuba to build economic partnerships elsewhere.”

Cuba presents a “Nixon goes to China” moment. Relaxing trade restrictions and putting the countries on a path to more normal relations, requires conservative, trade-oriented Republicans, like Crapo, to keep pushing.

In a 2005 report, the libertarian-leaning CATO Institute, labeled our country’s Cuba policy “four decades of failure.” CATO’s trade policy director Daniel Griswold wrote: “The most powerful force for change in Cuba will not be more sanctions, but more daily interaction with free people bearing dollars and new ideas.” Indeed.

World-class cigars aside, Cuba can’t have much to sell to us. They import most of their food and manufactured goods. By contrast, we have everything the Cubans need from automobiles to high rise resort hotels, from Idaho potatoes to Washington apples. Continuing sanctions is simply a huge missed opportunity.

Jimmy Carter left office in 1981 with a 34% approval rating. His tenure remains controversial, but his standing in the history books aside, Carter has quietly and effectively been a model “ex-president.” His selfless work in Africa to end disease, his election monitoring around the world and his advocacy for women continue to be impressive. As one of the few Americans to engage at the highest levels with Cuba’s political elite, with dissidents, artists and religious leaders, he deserves a fair hearing on Cuba.

Pure south Florida politics aside, when Jimmy Carter and Mike Crapo are on the same page about Cuba, everyone should be listening.

 

Egan, Idaho Politics, Journalism, Medicaid

The Moral Test

medicaidHard Cases

“The moral test of government is how that government treats those who are in the dawn of life; the children, those who are in the twilight of life; the elderly, and those who are in the shadows of life, the sick, the needy and the handicapped.”

The quote is most often attributed to the liberal icon Hubert Humphrey and dates to a time when there was a broad consensus in American life that government had a very precise role to play in trying to improve the plight of those fellow citizens “in the shadows of life.” The lingering Great Recession more than ever has called that role of government into question and, at the same time, made Hubert’s eloquent quote more relevant than ever.

A massive human hurt is unfolding in nearly every state as governors and state legislators contemplate unprecedented reductions in spending on various services paid for at the state level by Medicaid. In states like Idaho, all the easy stuff has been cut. Now the real pain begins, as illustrated by the estimated 1,000 Idahoans who showed up on Friday, some in wheelchairs, to show state legislators, more eloquently than words ever could, just what the American social safety net really means to real people.

With the 50 states collectively facing a budget gap estimated at $125 billion, the New York Times reports today that Medicaid is “ripe for the slashing” from New York to California, from Idaho to Texas. The times are tough – very tough – but I doubt that even tough-minded, fiscally conservative legislators can live with the implications of ending services for a guy in a wheelchair or an 8th grader with autism.

In Idaho, 20 lawmakers, the members of the powerful Joint Finance-Appropriations Committee (JFAC), make most every spending decision for the rest of the 85 members of the legislature. It is an awesome power and responsibility. The committee has co-chairs, Sen. Dean Cameron and Rep. Maxine Bell, and no one has ever credibly accused these experienced lawmakers of being big spenders. They run a tidy ship and one has to be impressed with the diligence they and their committee have lavished on the hard choices the state faces with both Medicaid and education. Cameron and Bell deserve a lot of praise for showing the political courage to open up the committee to those thousand people who came calling on Friday. It had to have been a sobering experience for anyone paying attention.

Here’s a fearless prediction. Arguably the most conservative legislature in the nation won’t be able to make the $25 million in Medicaid cuts that Idaho’s governor has proposed. It will take a while yet for the reality to sink in, its still early in the legislative process, but Friday was an important day. Not only did the thousand show up, but the budget numbers that have been in dispute since the first day of the 2011 session just gained some clarity and not in a good way.

All this will eventually lead to a frantic search for some barely acceptable source of new revenue to help plug the budget holes. The legislature will come to embrace, in tried and true fashion, the method of patch and scratch tax policy making. Some how, some way, Idaho’s very conservative legislature will “find” some new revenue to avoid these awful choices.

It won’t be easy, and people elected never to raise taxes will anguish over the choices, but it will happen I think. Idaho’s lawmakers have come face-to-face with their fellow citizens who really do, through no fault of their own, live in the shadows. In the end, it will not really be much of a political test. No one is likely to lose an election by making a vote to preserve home care services for an elderly, wheelchair bound neighbor. It will be quite a moral test, however, for lawmakers who infrequently see so clearly the impact of their votes.