RUTHFULLY YOURS

Joel Zinberg, M.D., J.D., F.A.C.S., a visiting scholar at the American Enterprise Institute, is a practicing surgeon at Mount Sinai Hospital and an associate clinical professor of surgery at the Icahn School of Medicine.

In the near term, the health-care plan that the Senate released this week—officially, the Better Care Reconciliation Act (BCRA)—will provide stability to individual health-care markets and state governments. It commits to funding the cost-sharing reductions that insurers are required to provide, but which Congress had not funded adequately through 2019. This should calm insurers uncertain about staying in the individual-insurance markets. Anthem, a major insurance player in both the Affordable Care Act (ACA) marketplaces and Medicaid, has announced that the Senate bill “will markedly improve the stability of the individual market and moderate premium increases.” The Congressional Budget Office predicts that premiums will be 30 percent lower than under current law by 2020. The BCRA will also allow insurers to charge older enrollees up to five times what they charge 20-year-olds—the standard before the ACA—rather than the 3-to-1 limit that Obamacare imposes. This should make the market more attractive to insurers and insurance more affordable for young people, who have resisted signing up under the ACA.

The BCRA also delays the end of enhanced federal funding for Obamacare’s Medicaid expansion and begins phasing it out with a gradual reduction in the enhanced federal payment share between 2021 and 2024. States would be free after 2024 to continue coverage for the expanded population covered under the ACA, but at regular federal matching rates. This should give governors ample time to plan if and how they want to continue expanded Medicaid eligibility. It will also give them time to expand private insurance markets to those at or below the poverty line, since the BCRA removes the lower income limit on premium tax credits to purchase insurance. Adults displaced by the phase-out of the Medicaid expansion and residents of states that did not expand Medicaid could use these credits to purchase private insurance.

In the longer term, the BCRA makes it far more likely that Obamacare’s section 1332 “innovation waivers” can become effective tools for state-based experimentation and reforms to improve insurance coverage. These waivers let states modify or eliminate many central ACA provisions, including the rules regarding the premium tax credits and cost-sharing subsidies and which plans and essential health benefits (EHB) must be offered on the insurance exchanges. The BCRA ends ACA restrictions that have inhibited waiver applications. It also streamlines the application process and creates a $2 billion fund to motivate states to apply for waivers.

But the Congressional Budget Office’s prediction that the BCRA will lead to 22 million more uninsured by 2026 has dampened enthusiasm for the Republican proposal—even among Republicans. The problem is that the CBO’s estimates of coverage under current law are based on its March 2016 baseline, which is known to be inaccurate. The CBO predicts that the BCRA will decrease coverage in the non-group market, including marketplaces, by 7 million, yet concedes that “enrollment in the marketplaces under current law will probably be lower than was projected under March 2016 baseline used in this analysis.”

The CBO’s estimate that 15 million fewer people will be covered by Medicaid in 2026 as compared with current law is also suspect. About a third of this loss derives from people whom “CBO projects would, under current law, become eligible in the future as additional states adopted the ACA’s option to expand eligibility.” It’s unlikely that the 19 states that have thus far not expanded eligibility under the ACA would expand if the law remains unchanged, especially since, under Obamacare, states now have to start sharing some of the financial burden for these newly eligible enrollees with the federal government.

WASHINGTON—Cities and counties that don’t help federal immigration authorities could lose millions of dollars in federal grants under legislation that passed the House on Thursday, as Republicans ramp up their battle against so-called sanctuary cities.

The legislation represents the Republicans’ most aggressive effort yet to force local communities to cooperate with President Donald Trump’s aggressive immigration-enforcement policies.

Mr. Trump and his administration regularly spotlight undocumented immigrants who commit crimes, and on Wednesday he met with their victims. After the bills passed Thursday, Mr. Trump said the “implementation of these policies will make our communities safer.”

The bill, along with a companion enforcement measure, represents a contrast with the comprehensive immigration legislation long pushed by Democrats and some Republicans. Those proposals typically combine enforcement measures with pro-immigrant provisions such as the legalization of people living in the U.S. illegally. But Mr. Trump and his allies in Congress have showed little interest in a bipartisan approach.

Both bills passed largely on party lines, and both are expected to face strong opposition in the Senate, where they would need Democratic support to pass.

The first bill, called the “No Sanctuary for Criminals Act,” primarily aims to persuade local jurisdictions to hold people in jail when asked to do so by the Immigration and Customs Enforcement agency. Proponents in the Trump administration and elsewhere say releasing criminals who should be deported makes communities less safe, They add that asking a jail to hold someone for up to 48 hours is a reasonable request.

“By flagrantly disregarding the rule of law, sanctuary cities are putting lives at risk and we cannot tolerate that,” said House Speaker Paul Ryan (R., Wis.).

Many local communities don’t honor these ICE “detainer” requests today for a range of reasons. Some say cooperation would undermine trust in law enforcement in immigrant communities, making legal and illegal immigrants less likely to report crimes. Some cite court rulings that found local communities are liable if someone such as a U.S. citizen is wrongly held based on inaccurate information.

Under the legislation, jurisdictions would lose federal grants from the Justice and Homeland Security departments if they enact policies restricting assistance with the enforcement of federal immigration law. CONTINUE AT SITE

No immigrant who has come to America has had an easy beginning. The difficulties are reflected in learning a different language with its mind-boggling idioms, understanding a new culture, and ultimately needing to be self-sufficient. Often education in the immigrant’s country is insufficient or completely lacking. Even those who are well educated in their birth country need to return to school to become properly licensed according to American standards.

Yet “[b]etween 1850 and 1930, about one million Asians from China, Japan, Korea, the Philippines, and India came to the United States. But by the second half of the 19th century a backlash had developed [.]” The 1882 Chinese Exclusion Act created increasingly restrictive laws against Asians. At one point, a law passed by the California State Legislature and signed by the governor created a $50 tax per head for Chinese entering Californian ports that was to be paid within three days. The California Supreme Court later ruled the law unconstitutional.

This discrimination was not limited to the Chinese. In the early 20th century, “[h]otels and clubs refused Jews admittance, and universities established Jewish enrollment quotas. Industrialist Henry Ford, a popular public figure, openly expressed anti-Semitic sentiments.” A notorious incident of anti-Semitism took place in Georgia in 1913, when Leo Frank, a Jewish factory superintendent, was convicted, on circumstantial evidence, of murdering a young girl and was lynched.

Then there was the “[d]iscrimination against Roman Catholics in the U.S. [which] began in the Colonial era, when Catholics were few in number. However, in the 1840s, the Catholic population expanded significantly when thousands of Irish Catholics immigrated to the U.S. following Ireland’s potato famine. In the late 1800s, a second flood of Catholic immigrants came from Eastern Europe and Italy. Protestants feared Catholics, coming from customs which included communal religious hierarchies, would not adapt to the individualism promoted by democracy.”

Furthermore, “[a]mong the Italian immigrants arriving in the late 1900s were large numbers of young men from southern Italy who hoped to earn money for the impoverished families they left behind. Discrimination against southern Italians was rampant. Newspapers fostered theories that Sicilians and other southern Italians were intellectually inferior to northern Europeans.”

So, sadly, discrimination has existed against many groups who eventually became Americans and shared in the American dream.

There are never excuses for the irrationality of prejudice. The latest shift in this country is where whites are now demonized in subtle and blatant ways just for being white. It is an idea being fostered in the halls of higher learning.

In the Pacific Standard Magazine of March/April 2017, an essay titled “The Mexican American Dream” begins with the following: “Despite the rhetoric and hate crimes, Mexican immigrants are poised to reframe American culture, if white people would only let them.” Clearly a provocative opener, it sets the stage for the “us against them” mentality that seems to be propelling all conversations these days. The narrative has become a brown-black vs. white storyline and has taken on a decidedly nasty racist overtone.

With this backdrop, the reader is supposed to feel an emotional angst for the protagonist of the article, named Vianney, who was born to “undocumented” parents. Her father had a drinking problem, and there was domestic violence. Despite drinking, taking drugs, and almost “flunking out of school,” Vianney was propelled into the Music Academy at the Colburn School in L.A., where she excelled. Noting the differences between the “world she had grown up and the [white] world of privilege, wealth, and status,” at one point, she “really wanted to be white.” Eventually, she “stopped trying to make herself seem white and started to embrace her Latina heritage.”

WASHINGTON—President Donald Trump declared a new age of “energy dominance” by the U.S. on Thursday as he outlined plans to roll back Obama era restrictions and regulations meant to protect the environment.

In a speech at the Energy Department, the president promised to expand the country’s nuclear-energy sector and open up more federal lands and offshore sites to oil and natural-gas drilling.

Mr. Trump also celebrated his decision earlier this month to withdraw the U.S. from the 195-country Paris climate accord and the Environmental Protection Agency’s rescindment this week of the Obama administration’s clean-water rules that farmers and business groups found onerous.

“We don’t want to let other countries take away our sovereignty and tell us what to do and how to do it,” Mr. Trump said.

Mr. Trump also issued a special permit authorizing the construction of a new pipeline between the U.S. and Mexico that would carry fuels across the border in Texas, the State Department said.

The president’s intent to resurrect coal and nuclear power comes as many other countries are trying to curb their use. He made only scant mention of renewable energy such as solar and wind power, which now account for 10% of total U.S. electricity generation and a far higher percentage in some European countries.

Mr. Trump’s speech caps a week the White House has devoted to energy issues. The proposals Mr. Trump laid out are in keeping with the more robust approach to energy extraction he promised during last year’s campaign and offer another instance of the new administration acting quickly to reverse his predecessor’s policies.

“We applaud President Trump’s support of energy policies that secure and expand U.S. energy supplies and position our country as a world supplier,” Barry Worthington, executive director of the U.S. Energy Association, said in a statement. “An all-of-the-above energy strategy… advances U.S. energy security, but it also protects our allies.”

Environmental groups criticized the moves as shortsighted and perilous for the environment. “Trump’s dirty energy nightmare is a wake-up call for the country,” said Rhea Suh, president of the Natural Resources Defense Council. “We get the [environmental] harm, foreign countries get the power, and big oil, gas and coal take the profits.”

The Wilderness Society homed in on the Trump administration’s opening of more Arctic waters to exploration after President Barack Obama had excluded Arctic Ocean lease sales as one of his last moves in office.

Senate conservatives wish the health-care bill was more ambitious on deregulation, and so do we, though the benefits of its state waiver feature are underappreciated and worth more explanation. This booster shot of federalism could become the greatest devolution of federal power to the states in the modern era.

One of ObamaCare’s most destructive legacies is a vast expansion of federal control over insurance and medicine—industries that did not exactly lack supervision before 2010. This included annexing powers that traditionally belonged to states. The Obama Administration then used regulation to standardize insurers as public utilities and accelerate a wave of provider consolidation that has created hospital and physician oligopolies across the country.

Once in command, the federal government rarely eases off or returns control, but the Senate bill does. The Affordable Care Act included a process in which states could apply for permission to be exempted from some rules, but conditions are so onerous that these 1332 waivers have been mostly notional. The Senate Republican draft bill makes this process quicker, more flexible and broader, which could launch a burst of state innovation.

The Senate bill is broader than the House’s Meadows-MacArthur waivers that only apply to a few so-called Title I regulations. Creative Governors could use the 1332 exemptions to explore a wider variety of reforms to repair their individual insurance markets, lower premiums and increase access to care.

Introducing many competing health-care models across the country would be healthy. California and South Carolina don’t—and shouldn’t—have to follow one uniform prototype designed in Washington, and even a state as large as California doesn’t have the same needs from region to region.

If nothing else the repeal and replace debate has shown that liberals, conservatives and centrists have different health-care priorities, and allowing different approaches and experimentation would be politically therapeutic. The more innovative can become examples to those that stay heavily regulated.

Some conservatives in the Senate and the House are despondent because neither bill repeals the federal rules related to pre-existing conditions known as guaranteed issue and community rating. They’re right that these mandates are destructive. Community rating, which limits how much premiums can vary among people with different health status and risks, tends to blow up insurance markets, as ObamaCare is now showing.

But at least for now, conservatives have lost this political debate. There’s no Senate majority for catching the pre-existing conditions grenade, Governors aren’t hot on the idea either, and even insurers don’t want to return to the days of medical underwriting.

The Senate bet is that the 1332 waivers can help create enough of a recovery in insurance markets to overcome the distortions of these rules and bring down rates. The bill also relaxes ObamaCare’s age bands to a 5 to 1 ratio from a 3 to 1 ratio, meaning insurance for the oldest beneficiaries can be priced five times as high as for the youngest. Since age is a proxy for health risks and expenses, and a 5 to 1 ratio is close to the true actuarial cost of care, the policy result in practice is a wash.

Former President Barack Obama is joining the demagogic slugfest against the GOP’s latest bill to repeal and replace Obamacare. He claims the bill would “ruin Medicaid.”

Not so fast, Obama. Your health care law ruined Medicaid. Now, about half of all women who give birth in the United States are on Medicaid, a staggering figure.
The Republican bill, awaiting Senate action, will reform Medicaid, restoring its original mission and ensuring its future.

Medicaid was created in 1965 as a safety net for the poor. But Obamacare distorted it, edging the U.S. closer to a Medicaid-for-all or single-payer system. Swelling the Medicaid rolls — not making private insurance affordable — is the main way Obamacare dealt with the uninsured.

Almost 75 million people are now enrolled, 20 million more than in Medicare, the program for the elderly. If the repeal bill doesn’t pass, Medicaid enrollment will soar to 86 million by 2026, according to a Congressional Budget Office analysis released Monday.

Who’s picking up the tab for this vast Medicaid expansion? You. Worse, you pay twice — once as a taxpayer, and then again as an insurance consumer. Families with private insurance pay $1,500 to $2,000 or more in added premiums yearly already to keep Medicaid afloat. The more Medicaid expands, the higher their premiums will go. That’s because Medicaid shortchanges hospitals and doctors, paying less than the actual cost of care. They make up for it by shifting the costs onto privately insured patients. Ouch.

That cost shifting only works until Medicaid enrollment grows too large. The Mayo Clinic warned three months ago that Medicaid enrollment has reached the tipping point. The renowned clinic announced it will have to turn away some Medicaid patients or put them at the back of the line, behind patients with commercial insurance.

Years earlier, when Obamacare was still being debated in Congress, the dean and CEO of Johns Hopkins Medicine, Dr. Edward Miller, issued a similar warning: Allowing a vast expansion of Medicaid could have “catastrophic effects” at places like Hopkins.

His dire prediction came true. Obamacare loosened Medicaid eligibility rules and urged states to enroll as many people as possible, with Uncle Sam paying 100 percent of the tab until 2016 and 90 percent or more thereafter.

Medicaid enrollment spiked in many states, including New York, where it skyrocketed up by a third to 6.3 million. Blame the incentive to rake in federal dollars.

And waste money. Roughly 10.5 percent of Medicaid payments are in error. Any company with that record would be out of business.