Vox - All
A critical mass of Republicans are rejecting the Senate health care bill
June 26th, 2017, 07:20 PM

“You’re either gonna get 50 or probably 35.”

Senate Republican leaders want to vote on their bill to repeal and replace Obamacare in three days, but a critical mass of senators have already said they would block the bill as written — and more could soon join them.

Senate Majority Leader Mitch McConnell is pushing for a vote by the end of the week and he can only lose two votes. But as it stood on Monday night, at least three Republican senators have said they would not support a procedural vote to start debate on the bill as currently written — enough to stop it if they hold firm.

Sens. Susan Collins of Maine, Dean Heller of Nevada and Rand Paul of Kentucky — two moderates and a conservative — say right now that they would block debate from starting on the bill. That vote could happen as early as Tuesday afternoon.

Conservative opposition to the plan is hardening, because they don’t believe it does enough to repeal Obamacare. Meanwhile, several moderates have expressed doubt, which would also sink the plan, especially now that the Congressional Budget Office projected Monday that 22 million fewer Americans would have health insurance under the plan.

There are still about 35 Republican senators who will vote for the bill no matter what. But the others will be the difference between failure and passage.

“You’re not gonna get 49. You’re either gonna get 50 or probably 35,” Sen. Lindsey Graham (R-SC) told reporters Monday, adding that the CBO estimates “are going to make it harder to get to 50, not easier.”

The Senate’s path to passing a health care bill is narrow

McConnell started with a narrow margin of error: 50 of the 52 Senate Republicans must support the bill, under the procedural shortcut Republicans are using to pass the plan with a bare majority of 50 and avoid a Democratic filibuster.

Conservatives have begun to revolt and moderates are blanching at the plan’s projected coverage losses. The majority leader has some room to negotiate; he has about $200 billion to play with, according to CBO. But any money he pumps into the bill to hold onto moderates could drive conservatives away. Likewise, moving the bill any further to the right — and potentially increasing that 22 million more uninsured estimate — could fortify moderate opposition.

About three dozen Republican senators would probably vote for any bill that McConnell put forward. They’re party people. But shoring up those last 15 or so votes is the trick.

Many congressional aides and lobbyists believe McConnell is pushing forward for a vote regardless of whether it would fail. He surely wants to pass a bill to repeal Obamacare, fulfilling a seven-year pledge that propelled him to power, but the effort has proved more difficult than Republicans expected.

Conservatives are hardening their opposition to the Senate bill

A quarter of conservative senators — Rand Paul, Mike Lee, Ted Cruz and Ron Johnson — announced their opposition to the bill last week. They’re holding firm.

Paul told reporters Monday that he would vote to block even a procedural vote to start debate on the legislation. If two of his peers join him, they could stop McConnell from even starting the amendment process, undercutting the bill well before the final vote.

“Of the current bill, yes,” Paul said when asked by reporters if he’d oppose that procedural vote. “Absolutely.”

Cruz told reporters that “significant work remains to be done” and argued that the plan didn’t do enough to lower premiums. CBO projected that premiums would eventually go down under the plan, but many Americans would have to pay higher out-of-pocket costs for their health care.

Johnson told me that he wanted to repeal the entire law, returning the health insurance market to what it was like before Obamacare. The current Senate bill keeps much of Obamacare’s infrastructure on the private insurance side, though it gives states more leeway to roll its regulations back and scales back the financial aid available to low and middle-income Americans. The bill also ends Obamacare’s Medicaid expansion and places a federal spending cap on the entire Medicaid program.

“I would recommend people go back to what were the conditions prior to Obamacare, embrace those conditions, embrace free markets,” Johnson said. “Get rid of the mandates that have artificially driven up the costs of insurance. We can do this... and solve the problem of preexisting conditions using high risk models."

But that is almost certainly a non-starter for a dozen or more Senate Republicans. Obamacare’s protections for people with preexisting conditions, particularly the requirement that health plans cover every American no matter their health status, are overwhelmingly popular.

Moderates are also starting to defect from the Senate plan

But McConnell has problems on the other ideological end of his conference, too.

Sen. Dean Heller (R-NV), a swing vote in a swing state who faces the toughest re-election race of any Republican next year, said Friday he would oppose the bill. He was joined by Nevada’s exceedingly popular Republican governor Brian Sandoval, who has also spoken out against the Senate plan for its Medicaid cuts.

“In this form, I will not support it,” Heller said, adding that he would also vote against the procedural motion to start debate on the bill. “It’s going to be very difficult to get me to a yes.”

Then on Monday evening, after the CBO report projected 22 million fewer Americans would have insurance under the Senate bill, Sen. Susan Collins (R-ME), another crucial moderate vote, said she would oppose the bill and the motion to start debate.

Collins, Heller and Paul make a trio that could block debate from starting on the legislation — and more senators may join them if the bill seems to be going down.

Several other moderate senators — Rob Portman of Ohio and Shelley Moore Capito of West Virginia — have fretted over the bill’s Medicaid cuts, and CBO projected that the current Senate bill would reduce the program’s spending by $772 billion over 10 years, versus current law.

Another, Sen. Bill Cassidy of Louisiana, demurred when asked whether he could support that procedural vote. He said he still needed time to understand the CBO report.

“You’d like to have questions answered before you proceed,” he said. Asked directly if he’d vote against the motion, Cassidy replied: “Can you talk to me tomorrow? Because I actually have not even considered that.”

McConnell still has room to maneuver, so it’s not over yet

But even if things are looking grim for the Senate health care bill right now, that doesn’t mean it’s game over yet.

“You don't want to bring something up unless you know you have the votes to pass it but I also think we may not know if we have the votes to pass it until we bring it up,” Sen. John Thune, the No. 3 Republican, told reporters Monday.

The complex Senate rules that Republicans are using to pass their bill with only 50 votes actually gives McConnell some new wiggle room based on the CBO score: He can add as much as $200 billion to the bill and still meet the budget targets that the rules require.

It’s not clear if more money is enough can bridge the ideological gaps that have divided Republicans. McConnell could shovel more money toward the opioid crisis, to help win over Portman and Capito. He could give Collins and Sen. Lisa Murkowski (R-AK), another moderate swing vote, a chance to remove Planned Parenthood defunding from the bill. He may bet on the goodwill of conservative senators who would rather vote for an imperfect bill than block Obamacare repeal.

It might not be enough.

“Health care was broken before Obamacare. Obamacare made it worse, and I don’t think we’re necessarily doing anything to fix the problem,” Paul said. “This is why it’s worse to pass a bad bill than it is to pass no bill..”

But even Paul, perhaps the most strident opponent of the bill right now, hinted at a path forward.

“You don’t have 50, you don’t have 52 for what’s in the bill now. How do you get there? You make the bill narrower,” he said. “Then maybe you pick up one. Then you make it narrower and narrower. So it’s not making the bill bigger, it’s actually making the bill more like a repeal bill.”

Tara Golshan contributed reporting.

Vox Sentences: SCOTUS gets the ban back together
June 26th, 2017, 07:20 PM

Vox Sentences is your daily digest for what's happening in the world, curated by Ella Nilsen . Sign up for the Vox Sentences newsletter, delivered straight to your inbox Monday through Friday, or view the Vox Sentences archive for past editions.

The Senate health care bill gets a CBO score; the US Supreme Court gives Trump a win on his travel ban; the prime minister of India goes to Washington.


CBOh no

 Chip Somodevilla/Getty Images
  • The latest version of the plan to repeal and replace the Affordable Care Act would leave 22 million people more uninsured by 2026, according to the latest report from the nonpartisan Congressional Budget Office. [Congressional Budget Office]
  • As expected, the bill would predominantly affect the poor. Many of those people who would lose insurance are low-income Medicaid recipients, as the bill would cut Medicaid spending by $772 billion over the next decade. [Vox / Dylan Scott]
  • Each time House and Senate Republicans release a new version of the bill, the number of uninsured people goes down by about a million (the health care bill passed by the House would have left 23 million uninsured, and an earlier version of that bill would have left 24 million uninsured). It’s still an extremely high number of uninsured people, and could prove to be too much for some Senate Republicans, who will decide the bill's fate.
  • Still, the bill is hurtling toward a vote before the upcoming July 4 recess. The bill was released on Thursday, and there are just a few more days until senators are expected to vote. A big consequence of the speedy process is less time to catch gaps in the bill, some of which have already been discovered. [Vox / Sarah Kliff]
  • One of the issues with the bill that consumer advocates recently noticed is that it could raise health insurance premiums for small businesses. Another glaring omission was the initial lack of a continuous coverage clause, which would penalize Americans for not maintaining their health insurance. That had been left out of the bill’s original draft, but made it into a newer draft released on Monday. [Vox / Sarah Kliff and Dylan Scott]
  • Right now, one of Mitch McConnell’s toughest challenges is satisfying concerns of both far-right Republicans and those in the middle, like Sens. Dean Heller of Nevada, Susan Collins of Maine, and Lisa Murkowski of Alaska. Murkowski has said she won’t vote for a bill that defunds Planned Parenthood (which this one does, for one year). [NYT / Robert Pear and Thomas Kaplan]
  • Then there are the conservatives. Republican senators including Rand Paul of Kentucky, Mike Lee of Utah, Ted Cruz of Texas, and Ron Johnson of Wisconsin say the bill simply doesn’t go far enough to cut costs. Johnson has also said he thinks there’s far too little time before the vote. [NYT / Robert Pear and Thomas Kaplan]
  • No matter the outcome, the bill simply does not make good on Donald Trump's repeated promise to lower health costs for Americans. During the 2016 campaign, Trump promised “insurance for everybody” that would be cheaper, and told his supporters he would not cut expanded Medicaid. Many of these people could see their insurance stripped or become a lot more expensive if the bill passes. [Washington Post / John Wagner, Abby Phillip, and Jenna Johnson]
  • For more health care coverage, don't miss Vox's daily health care newsletter, edited by Sarah Kliff. [Click here to subscribe automatically for this email address.]

Trump's travel ban is back — for now

Protestors Rally Against Muslim Immigration Ban At Miami Airport Photo by Joe Raedle/Getty Images
  • President Trump scored a big — if temporary — win on his travel ban today, as the US Supreme Court announced it would hear arguments on the ban later this fall and, in the meantime, lifted a block the lower courts had placed on its implementation. [Vox / Dara Lind]
  • The people primarily affected by the Court’s decision are tourists from the six majority-Muslim nations — Iran, Libya, Somalia, Sudan, Syria, and Yemen — as well as refugees. (Iraq was in Trump’s first ban but has since been cut.) The ruling will not affect foreigners coming into the US to study, teach, or work at American businesses. It also won’t impact people who are coming to stay with family members. [Vox / Dara Lind]
  • That is less restrictive than what the Trump administration initially wanted; the initial executive order Trump signed on January 27 applied to students, workers, and people who were coming to the US to visit family. At least three of the Supreme Court justices agree with him. Clarence Thomas, Samuel Alito, and newest Court member Neil Gorsuch wrote they would have supported the ban taking full effect, with even more restrictions on travelers. [BuzzFeed / Chris Geidner]
  • Up until this point, ruling of these lower courts has allowed travel and refugee resettlement programs from these countries to go on unimpeded.
  • In a statement released this afternoon, Trump praised the Court’s decision to take up the case and called the ruling a “victory” for the country’s national security. [Bradd Jaffy via Twitter]
  • From the beginning of the ban, the Trump administration has argued that barring people from the majority-Muslim nations designated by his administration will keep the country safer. But that’s a dubious claim to make, given that none of the perpetrators in 9/11 or the 10 fatal attacks on US soil since then are from those countries. [Washington Post / Mark Berman]
  • In fact, several of the attackers in the shootings and attacks since 2001 were born in the United States and later radicalized. The majority of the attackers were born in Saudi Arabia, a key US ally that Trump visited last month. [Washington Post / Mark Berman]
  • Trump’s first ban caused massive protests and chaos at US airports when it was first implemented. Soon lower courts started ruled against the ban, saying it is unconstitutional because it discriminates against people based on their nationality or religion. Trump’s own rhetoric against Muslims was cited by federal judges in their ruling on the issue. [CNN / Steve Almasy and Darran Simon]
  • As drafted by the Trump administration, the ban is supposed to be temporary, with the moratorium on travel taking place for 90 days and a 120-day halt to the refugee program while the government looks at how it vets refugees. While the Court plans to hear the case, it could be moot by then, because the ban’s timeline could potentially be up. [Washington Post / Robert Barnes]

Modi goes to Washington

 Win McNamee/Getty Images
  • Today’s meeting between President Trump and Indian Prime Minister Narendra Modi in Washington, DC, is being billed as a business-as-usual meeting between the world’s two biggest democracies.
  • But beneath the surface of the “no frills” visit by Modi, there are serious issues between India and the United States that are being hammered out, especially when it comes to immigration and climate change policy. [Washington Post / Max Bearak]
  • Among the most contentious issues for the two leaders is the future of the H-1B visa program under the Trump administration. The program allows high-skilled workers to come work in the US, and it’s especially important for the tech industry and Silicon Valley. [Recode / Tony Romm]
  • On the campaign trail, Trump had promised to end the program “forever.” In April the US Department of Homeland Security announced it would be taking a closer look at H-1B applicants, and the Department of Justice warned employers not to discriminate against American workers over foreign ones. This had important implications for Indian workers, who get three-quarters of the program’s visas. [Washington Post / Tracy Jan]
  • Anti-immigration rhetoric became especially serious earlier this year, when two Indian engineers were shot at a bar in Kansas by a man who had told them to get out of his country. One later died, and the incident sparked fears of increased hate crimes toward Indians in the US under Trump. [NYT / John Eligon, Alan Blinder, and Nida Najar]
  • Climate change, and Trump’s public griping about India’s energy production, is another issue where the American president and Modi are at odds.
  • Announcing his decision to pull out of the Paris climate accords earlier this month, Trump complained that India would be able to double its coal production, which he thought was an unfair double standard. India is the third-biggest emitter of carbon dioxide behind China and the United States, and as a developing nation, it’s trying to grow its economy quickly, emitting lots of greenhouse gases in the process. [CNN / Ben Westcott]
  • But Modi has also spoken out about the risks of climate change after growing anger in the country over air pollution and recognition that India and its economy will suffer under a warming climate. [Reuters / Nita Bhalla]
  • Beyond these issues, some hope Modi’s visit will help put to rest the notion that relations with India just aren’t much of a priority for the Trump administration, which has yet to appoint an ambassador to the country. [NPR / Julie McCarthy]
  • Don’t expect any quick answers to these questions; Modi’s visit was not open to questions from the press. [David Makamura via Twitter]

Miscellaneous

  • Leigh Ann Wilson voted for Donald Trump because she believed he would solve the opioid crisis in her home state of West Virginia. This weekend, she spoke at Bernie Sanders’s health care rally in the state, slamming Trump for his response to the opioid crisis so far. [STAT / Max Blau]
  • As a 19-year-old college student at Harvard, Jared Kushner got his feet wet with real estate deals in Somerville, Massachusetts. He made millions, but many of his properties had serious problems and complaints from tenants. [Boston Globe / Matt Viser]
  • Nursing home residents are still prime targets for abuse on social media, as care workers take demeaning and in some cases vulgar photos and videos of them on Snapchat and other social media apps. Despite getting more scrutiny from government officials, it’s an ongoing problem. [ProPublica / Charles Ornstein]
  • Venmo revolutionized the way people can pay each other, wiring money through apps. Now, it’s planning to develop its own debit card. [Recode / Jason Del Ray]
  • Undocumented immigrants who fled to Canada after Trump was elected are now stuck in legal limbo, as the sheer number of new people is swamping that country’s immigration system. Without the right papers, people’s lives are on hold — they can’t work or go to school. [Reuters / Anna Mehler Paperny and Rod Nickel]

Verbatim

  • "It really is a 747 landing on a suburban driveway." [Josh Holmes to Axios / Jonathan Swan]
  • “We used to go after newsmakers no matter what side they were on. And Trump is a guy who is running for President with a closet full of baggage. He’s the ultimate target-rich environment. The Enquirer had a golden opportunity, and they completely looked the other way.” [National Enquirer staffer to Jeffrey Toobin / The New Yorker]
  • “John Mayer? You don’t see a bunch of kids emulating John Mayer and listening to him and wanting to pick up a guitar because of him.” ]George Gruhn to Washington Post / Geoff Edgers]
  • “It very much started, as the lore goes — and there’s always stories told about cocktails that aren’t really verifiable because people are drinking and not writing stuff down — that Allen’s started as something the lobstermen would take out with them and put in their coffee as they went out on the water at three, four in the morning.” [Andrew Volk to Atlas Obscura / Dan Nosowitz]
  • “As more young people decide to pursue four-year degrees, college towns are siphoning students out of the rural heart of the Farm Belt and sending them, degrees in hand, not back to Oskaloosa but to the nation’s urban centers.” [WSJ / Dante Chinni]

Watch this: The origin of the ’80s aesthetic

The design phenomenon that defined the decade. [YouTube / Dion Lee]


Read more

How repealing Obamacare could splinter neighborhoods

What conservatives know about climate change that liberals don’t

How a Canadian sniper shot someone more than 2 miles away, explained by a Canadian sniper

Handstands, explained

The cruel reality of high-speed health care legislating

CBO: defunding Planned Parenthood would result in thousands more unplanned pregnancies
June 26th, 2017, 07:20 PM

The GOP’s Better Care Reconciliation Act will make it more difficult for women to access birth control and family planning services.

The nonpartisan Congressional Budget Office’s new estimate on the impact of the GOP health plan to repeal and replace Obamacare projects 22 million fewer people will have insurance by 2026 if the plan is enacted.

It’ll also result in thousands of unintended pregnancies, since the bill restricts funding for Planned Parenthood, which offers women family planning and abortion services.

Margot Sanger-Katz at the New York Times noticed the key passage today:

If you search the latest draft of the bill and its amendments for precise language about Planned Parenthood, you won’t find it. But the bill’s provisions about “prohibited entities” are basically attempts to defund it.

In essence, these sections of the bill say groups that are primarily engaged in family planning services, reproductive health, and providing abortions (other than abortions that are medically necessary or responses to cases of incest or rape) — and whose Medicaid receipts exceeded $350 million in fiscal year 2014 — are barred from receiving federal dollars through several health programs, most importantly Medicaid, for one year. And one group that obviously meets that description is Planned Parenthood.

If passed, the provision would mean that if a woman has Medicaid, the health insurance program for low-income Americans, as her health insurance plan, she can’t go to Planned Parenthood and get those services covered because Planned Parenthood would no longer be able to be reimbursed for these services.

The impact here would be huge. Three-quarters of the public dollars spent on family planning in this country are Medicaid dollars. And right now about 2.5 million people rely on Planned Parenthood for a range of health care services, like birth control and cancer screenings.

Defunding Planned Parenthood will leave thousands of people, particularly low-income people, without access to these health care services — and would also result in more unintended pregnancies, CBO said (emphasis added):

To the extent that access to care would be reduced under this legislation, services that help women avoid becoming pregnant would be affected. The people most likely to experience reduced access to care would probably reside in areas without other health care clinics or medical practitioners who serve low-income populations. CBO projects that about 15 percent of those people would lose access to care.

The Better Care Reconciliation Act also guts Medicaid, which pays for about half of all births in this country, including two-thirds of unplanned births.

The core idea behind the BCRA is cutting spending on health care for the poor to finance tax cuts for the rich, as Vox’s Andrew Prokop explained. In practice, this means phasing out Medicaid expansion (which made more people eligible for the program) by 2021.

If fewer people can access Medicaid, that means fewer people can get the women’s health and reproductive services that do things like cover cancer screenings, improve access to birth control, and make sure moms and babies have health care throughout a pregnancy and in the months after a baby is born.

Here’s the CBO again, on the impact that’ll have:

Because the Medicaid program pays the costs of about 45 percent of all births, CBO estimates that the additional births stemming from the reduced access under this legislation would add to federal spending for the program. In addition, some of those children would themselves qualify for Medicaid and possibly for other federal programs. By CBO’s estimates, during the one-year period in which the funding prohibition would apply, the number of births in the Medicaid program would increase by several thousand, increasing direct spending for the program by $79 million over the 2017-2026 period. Overall, with those costs netted against the savings estimated above, implementing the provision would reduce direct spending by $146 million over the 2017-2026 period, CBO estimates.

Some of these provisions may not pass the Senate

The Senate chose to try to pass their health reform bill through budget reconciliation, a process that allows bills to pass with only 50 votes, as Vox's Dylan Scott explained.

The reconciliation process was designed for dealing with bills related to the federal budget, and specifically budget deficit reductions. Under Senate rules (the Byrd Rule in particular), bills passed this way are supposed to be focused on the budget.

Anything in the bill designed for other purposes is suspect and may be stripped out — and the defunding of Planned Parenthood is something that may violate these Senate rules. If the bill is allowed to stand as is, though, it would have a major impact on women and, eventually, their children.

“Sen. Heller: Keep Your Word” banner shown in West Virginia instead of Nevada
June 26th, 2017, 07:20 PM

Heller’s vote on health care is important, but…

Winning over both Sen. Dean Heller (R-NV) and Sen. Shelley Moore Capito (R-WV) will be critical to the Senate GOP in getting their health care bill to 50 votes.

Unfortunately, per a tweet from Charleston Gazette-Mail executive editor Rob Byers, someone seems to have confused the two lawmakers.

On Monday afternoon, a small plane toting a sign reading, “Sen Heller: Keep your word [and] vote no on Trumpcare,” passed over Charleston, West Virginia.

Heller of Nevada is one of the five GOP senators openly opposing the Republican plan to replace Obamacare, and Capito of West Virginia is still on the fence about the bill.

Per reporting from the Gazette-Mail, a progressive women’s activist group called Ultraviolet was behind the message. According to a press release from the organization, planes with similar messages flew over Las Vegas, Nevada, and Portland, Maine, as well.

Portland apparently got the correct banner (which called out Sen. Susan Collins), but it remains unclear if voters in Nevada looked up at a message for Capito.

McCain on CBO projection of 22 million fewer insured: “Obviously, that’s not good news”
June 26th, 2017, 07:20 PM

Sen. John McCain (R-AZ) explained on Monday that he’s not excited about 22 million fewer Americans having access to health insurance — even as he supports a health care bill that would result in that precise outcome.

On Monday, the Congressional Budget Office released a report estimating that upward of 22 million fewer Americans would have insurance if Republicans’ Better Care Reconciliation Act were signed into law.

Asked by reporters in the Russell Senate Office Building shortly afterward the report came out, McCain confirmed that he would indeed regard this as an undesirable outcome: “Well, obviously that’s not good news,” he said about the massive coverage losses.

Despite saying he was discomfited by the news, McCain has shown no appetite to oppose the BCRA. Losing McCain would almost certainly doom Senate Majority Leader Mitch McConnell’s attempts to pass the bill, given that Senate Republicans can only afford two defections and still pass the legislation. But in his interview, McCain seems to cast the coverage losses as one factor among many to consider.

“We’ll have conversations and go through the whole bill together, and have time to discuss it and decide,” he told reporters. “It will have to be a factor, an important factor.”

What’s so jarring about this particular clip is the disconnect between the gravity of what McCain is acknowledging and his on-camera flippancy. McCain understands that 22 million fewer Americans will have health insurance if the Republican bill passes. But he doesn’t seem alarmed enough to commit to voting against it.

Page 48 is the most important page in the CBO report
June 26th, 2017, 07:20 PM

This is the web version of VoxCare, a daily newsletter from Vox on the latest twists and turns in America’s health care debate. Like what you’re reading? Sign up to get VoxCare in your inbox here.

The Congressional Budget Office estimates that 22 million Americans would lose coverage under the Senate health bill. This would mean the uninsured rate would rise significantly over the next decade.

 Alvin Chang/Vox

The CBO report is a dense 49-page document that you can read here. But you can find its clearest explanation of the Senate bill on page 48. This is where the CBO report explains how premiums would change for low- and middle-income Americans — and what type of health insurance they would get for those monthly payments.

This page shows, in no uncertain terms, that low-income Americans would be asked to pay higher premiums for worse health insurance coverage.

Look at what happens to people who earn $26,500 (175 percent of the poverty line). I've circled the most relevant numbers below.

You can see that across the board, premiums go up for Americans with low to moderate incomes. People who purchased bronze-level plans would see their premiums go up a little. People who purchased silver-level plans would see their premiums go up a lot.

What is harder to see is that the premiums are up while the quality of the health insurance is going down. Those numbers in the gray boxes represent actuarial value, which measures how much a health plan, on average, covers of its members' costs. You can see that the actuarial value drops as premiums rise.

This, in simple terms, means enrollees will be asked to pay higher premiums and in return get coverage with higher deductibles and copayments.

The reality, of course, is that many of these people just wouldn't buy coverage. They would find the plans prohibitively expensive and the coverage not worth the price. This is what the CBO concludes in one especially devastating paragraph (bolding mine):

Under this legislation, starting in 2020, the premium for a silver plan would typically be a relatively high percentage of income for low-income people. The deductible for a plan with an actuarial value of 58 percent would be a significantly higher percentage of income — also making such a plan unattractive, but for a different reason. As a result, despite being eligible for premium tax credits, few low-income people would purchase any plan, CBO and JCT estimate.

One problem this Senate bill does solve is helping some especially low-income Americans who didn't qualify for tax subsidies under the Affordable Care Act. This was an odd drafting quirk: The law presumed these people would enroll in Medicaid expansion before the Supreme Court gave states the ability to opt out of the program.

Those people would qualify for subsidies under the Senate bill, lowering the premiums of a 40-year-old who earns $11,000 significantly. You can see that in the first lines of the chart above.

But it's not clear that this would matter that much: At that income level, any level of subsidy (again, for a plan with a high deductible) may not be an attractive option. The CBO makes this clear in one other chart that is worth pausing on:

This chart shows that the people who lose badly in the Senate bill are Americans with lower incomes. They would see the steepest rise in uninsured rates, just as this group saw the biggest gains under the Affordable Care Act.

The Senate bill provides current Affordable Care Act enrollees with a stark choice: You can pay more and get less, or you can decide to drop coverage. The CBO estimates that millions of Americans will, understandably, make the latter decision.

Defector of the Day: Ron Johnson

Each day leading up to the Senate vote, we'll take a closer look at a Republican senator who seems to be on the fence on the Better Care Reconciliation Act, what they want, and what role they're likely to play in the debate. On Friday, we kicked off with Nevada Sen. Dean Heller. Today we move eastward with some news from Wisconsin Sen. Ron Johnson.

 Alex Wong/Getty News Images

Johnson already made waves last week when he joined a trio of the Senate's most conservative Republicans (Sens. Ted Cruz, Mike Lee, and Rand Paul) Thursday to announce they could not endorse the Senate health bill in its current form.

Since then, however, Johnson has somewhat surprisingly emerged as one of the most outspoken critics of the BCRA. He wrote Monday in a New York Times op-ed that the current bill from Senate Majority Leader Mitch McConnell (R-KY) “leaves in place the pre-existing-condition rules that drive up the cost of insurance for everyone.”

Johnson also appeared on Meet the Press this past Sunday, where he criticized the health care process too. “We don't have enough information,” he said. “I don't have the feedback from constituencies who will not have had enough time to review the Senate bill. We should not be voting on this next week.”

What will get Johnson to yes: Johnson seems to be angling for relaxing some of the Affordable Care Act's insurance market regulations and wants a bit more time to consider the bill.

Stat of the Day

 Javier Zarracina/Vox

The House bill's tax cuts for the wealthiest 400 families are equivalent to ending federal funding for Medicaid expansion in four states. This would end coverage for an estimated 725,800 Medicaid enrollees. Read more here.

Kliff’s Notes

Your daily top health care reads, with research help from Caitlin Davis

Today's top news

  • "The Senate just released a new draft of its health bill. Here’s what changed." "The new bill includes a six-month waiting period for those who want to purchase individual market coverage but have had a more than two-month break in coverage at some point in the past year." —Sarah Kliff and Dylan Scott, Vox
  • "Insurers' losses on ACA plans narrow in 2016": "Health insurers lost less money on individual insurance plans in 2016 than they did the year before, but those losses still totaled billions of dollars. Insurers selling plans in the individual insurance market on and off the exchanges lost between 7% and 9% of premiums, compared with 10.1% of premiums in 2015, according to a report released Friday morning by consultancy McKinsey & Co. That's because enrollment increased in individual plans last year, so insurers made more in revenue." —Shelby Livingston, Modern Healthcare
  • "Health Bill Provision Favors States That Didn’t Expand Medicaid": “As health-care companies parse Senate Republicans’ bill to undo the Affordable Care Act, a rift is emerging in the hospital industry over a provision that would award additional funds in states that didn’t expand Medicaid. The split centers around cuts the Affordable Care Act made to Medicaid subsidies known as 'disproportionate share' payments, for hospitals that care for a large share of uninsured patients.” —Melanie Evans, Wall Street Journal
  • "GOP's Obamacare repeal bills threaten huge disruptions across the healthcare system": “In physicians’ offices and medical centers, in state capitols and corporate offices, there are growing fears that the unprecedented cuts proposed in the GOP legislation would create even larger problems in the U.S. healthcare system. 'These reductions are going to wreak havoc,' warned Tom Priselac, chief executive of Cedars Sinai Health System in Los Angeles, one of the country’s leading medical centers. 'It will be a tragic step backward not just for the people most affected, but for the country as a whole.'” —Noam N. Levey, Los Angeles Times
  • "In the End, Even the Middle Class Would Feel GOP Cuts to Nursing Home Care": "A combination of longer life spans and spiraling health care costs has left an estimated 64 percent of the Americans in nursing homes dependent on Medicaid. In Alaska, Mississippi and West Virginia, Medicaid was the primary payer for three-quarters or more of nursing home residents in 2015, according to the Kaiser Family Foundation." —Jordan Rau, Kaiser Health News

Longer reads and analysis

Join the conversation

Are you an Obamacare enrollee interested in what happens next? Join our Facebook community for conversation and updates.

The CBO chart that shows the Senate health care bill is really about tax cuts
June 26th, 2017, 07:20 PM

It’s hard to miss the fundamental design of the Senate’s health care plan to repeal and replace Obamacare: a bill that makes deep cuts to services for low-income Americans to pay for tax cuts that would largely benefit the country’s wealthiest.

The Congressional Budget Office’s report now confirms it: Medicaid, a health service for poorer Americans, as well as the disabled and elderly, would see a $772 billion cut over the next 10 years.

To what end? This chart in the CBO’s report is a telling diagram of why Republicans are trying so adamantly to gut the program: They’re trying to offset the cost of tax cuts to reduce the deficit. Here is the chart:

 Congressional Budget Office

As you can see, on one side there are the parts of the health care bill that would increase the deficit, the majority of which come from the “repeal or delay of taxes on high income people, fees on manufacturers and excise taxes enacted under AHCA” — in other words, cutting taxes on the rich and corporations.

Then in the “savings column,” there is $772 billion from a “reduction and termination of enhanced federal matching funds” and “per capita-based cap on Medicaid payments.” This is in reference to the part of the health care bill that looks to phase out Medicaid expansion in 2021 and restructure funding for the program that would ultimately result in less funding to states for Medicaid.

Vox’s Sarah Kliff explained this major change in the programs:

This bill would convert Medicaid to a “per capita cap” system, where states would get a lump sum from the federal government for each enrollee. Or states would have the opportunity of a block grant — a sum of money untethered from the number of people involved.

This is very different from current Medicaid funding. Right now the federal government has an open-ended commitment to paying all of a Medicaid enrollee’s bills, regardless of how high they go.

The Senate bill would set different amounts for different groups of people. It envisions, for example, likely higher payments to cover Medicaid enrollees who are disabled (and tend to have higher costs) than Medicaid enrollees who are kids (generally healthy with lower costs).

The CBO is laying out clearly: The Better Care Reconciliation Act of 2017 reduces the deficit overall by $321 billion over the next 10 years — a major goal of conservatives — but does so on the backs of the most vulnerable Americans in exchange for tax cuts.

As Vox’s Andrew Prokop put it, there’s no hiding it: “It’s a massive redistribution from the poor to the rich.”

The CBO just undermined a big GOP talking point on the Senate health bill
June 26th, 2017, 07:20 PM

Some areas still won’t have insurance providers on individual exchanges.

Republicans are speeding their health care bill through the Senate, releasing the text last week and preparing to vote as soon as this week. When asked why the rush, one of the first answers GOP leaders often give is that Congress must take action now to save individual insurance exchanges set up under the Affordable Care Act, which Sen. John Cornyn (R-TX) told reporters this weekend are in “full meltdown mode.”

One piece of evidence for that meltdown is the scattered — but growing — number of rural counties, in states such as Missouri and Ohio, where no insurer will offer a plan on the individual market. Republicans must repeal and replace the ACA, the argument goes, in order to give residents of those areas choices for insurance.

But the Congressional Budget Office just said the Senate bill will not, in fact, solve that problem. From its assessment of the bill, released Monday afternoon:

In the agencies’ assessment, a small fraction of the population resides in areas in which — because of this legislation, at least for some of the years after 2019 — no insurers would participate in the nongroup market or insurance would be offered only with very high premiums. Some sparsely populated areas might have no nongroup insurance offered because the reductions in subsidies would lead fewer people to decide to purchase insurance — and markets with few purchasers are less profitable for insurers. Insurance covering certain services would become more expensive — in some cases, extremely expensive — in some areas because the scope of the EHBs would be narrowed through waivers affecting close to half the population, CBO and JCT expect. In addition, the agencies anticipate that all insurance in the nongroup market would become very expensive for at least a short period of time for a small fraction of the population residing in areas in which states’ implementation of waivers with major changes caused market disruption.

To repeat: “Some sparsely populated areas might have no nongroup insurance offered.” That seems like a messaging challenge for Republicans selling the speedy process, and the bill.

These are all the people the Senate health care bill will hurt
June 26th, 2017, 07:20 PM

The actual policies contained in the Better Care Reconciliation Act, the Senate Republican plan introduced on Thursday to repeal and replace Obamacare, would help some Americans a lot. The biggest winners are households making $250,000 a year or more, which would see two different taxes targeting them repealed; households with millions in investment income would come out particularly far ahead.

But vastly more Americans would come out behind. 22 million will lose health care coverage, according to the Congressional Budget Office estimated would lose insurance under the bill that passed the House in May. Medicaid beneficiaries will have to deal with $774 billion in cuts over ten years, plus additional ones in years after that.

And because the bill substantially weakens regulations for both individual and employer plans, millions of people who still get insurance will see the extent of their coverage shrink, and see themselves forced to pay out of pocket for expensive procedures that would otherwise be covered.

The list of people losing out from the bill doesn’t end there, though. Here are a few of the main groups that will be negatively affected if this legislation becomes law.

1) Working poor people who gained Medicaid under Obamacare

Of the 22 million people the CBO projected would lose coverage under the Senate bill, 15 million are currently covered by Medicaid, which the bill would cut by about $774 billion over 10 years.

These are the poorest and most vulnerable people who’ll lose insurance under the bill.

In the 31 states (and Washington, DC) that expanded Medicaid following the Affordable Care Act, all adults earning up to 138 percent of the poverty line are eligible for Medicaid. Non-expansion states often feature much lower income thresholds to qualify for Medicaid, particularly for non-parents — but they will also see people lose coverage.

The BCRA would effectively end the Affordable Care Act’s Medicaid expansion starting in 2021. Under current law, the federal government initially paid 100 percent of costs of Medicaid expansion beneficiaries, a percentage set to wind down to 90 percent in 2020 and stay at that level permanently. Under the BCRA, the federal government would gradually wind down that percentage to the states’ normal matching rates for Medicaid — rates that are as low as 50 percent in certain states.

The Congressional Budget Office has argued that this will mean no more states pursue expansion. It will also spark states with “trigger laws” — which end the expansion if there’s any reduction in the federal match — to automatically abandon it starting in 2021. Those states are Arkansas, Arizona, Illinois, Indiana, Michigan, New Hampshire, New Mexico, and Washington.

Joan Alker, a Medicaid expert at Georgetown University, estimates that those eight states alone could lead to 3.3 million Medicaid enrollees losing coverage. But many of the other 24 states will abandon the expansion due to the lower match rate as well. And keeping it going will be even harder due to other, fundamental changes the bill makes to the Medicaid program.

2) Seniors, disabled people, and others who qualified for Medicaid even before Obamacare

But it’s not just people who gained coverage under Obamacare’s Medicaid expansion who would lose out. The law would also adopt a policy known as a “per capita cap” for Medicaid that would hurt all beneficiaries.

Currently, the federal government matches state spending on Medicaid, offering about $1 to $2.79 for every dollar states spend on it. Poorer states get a bigger match. But the BCRA would change all that.

Rather than matching state Medicaid spending, the AHCA would give each state a set amount of money per person. Until 2025, the amount would grow from year to year according to the medical component of the Consumer Price Index, to account for inflation. Then it would switch to the overall CPI.

The medical component of CPI is growing more slowly than Medicaid costs are expected to grow right now, according to the Center on Budget and Policy Priorities, and the CPI as a whole grows far more slowly. So switching to a per capita cap is essentially a federal cut to Medicaid amounting to hundreds of billions over 10 years. We’ll have to wait for the CBO report to know exactly how many hundreds of billions.

A per capita cap is at least somewhat responsive to changes in Medicaid enrollment — unlike a block grant, which gives states a set amount of money, it gives them a set amount of money for every person who’s eligible. But it could lead to cuts in some other ways as well. Take a state like Florida that’s aging fast. The BCRA includes separate caps for different groups of beneficiaries — the elderly, disabled, non-elderly adults, etc. — so states can’t get more money by dumping lots of seniors in favor of 24-year-olds.

However, there is still a lot of variation in cost within those categories. “Within your elderly group, you have the young and old, 67-year-olds and 85-year-olds, and the latter are much more expensive,” Georgetown’s Alker told me in March. A state like Florida, which has a large senior population, could see costs rise fast as its population ages with time. But a per capita cap wouldn’t keep up with that. To get around that, the state might be motivated to kick off older seniors and focus enrollment on younger ones.

There are some federal requirements as to whom states must cover, but they only go so far, and most states now provide additional coverage that they can roll back. “You do have to cover people on Supplemental Security Income” — a program for disabled, elderly, and blind people with low incomes — ”but a lot of folks in nursing homes [are] optional coverage,” Alker continued.

This helps explain why disability rights activists are appalled by the per capita cap plan. “People with disabilities who rely on home- and community-based services through Medicaid — such as personal-attendant care, skilled nursing, and specialized therapies — could lose access to the services they need in order to live independently and remain in their homes,” the Center for American Progress’s Rebecca Vallas, Katherine Gallagher Robbins, and Jackie Odum note.

As if that weren’t enough, the bill has also been changed to allow states to impose work requirements on Medicaid, a policy that would not effectively spur people to work or reduce poverty but that could meaningfully reduce access to care for poor families, and which even many conservative health care experts oppose.

3) People hard hit by the opioid crisis

Battleground State Of Ohio Key To Winning Presidency For Candidates Photo by Spencer Platt/Getty Images
Dora Reynolds, who is currently unemployed, sits along a road downtown on October 24, 2016, in East Liverpool, Ohio, a state hurt by the opioid epidemic.

A per capita cap would also cause problems if a new, expensive, but necessary drug comes on the market, or an epidemic hits. Those are both changes that would raise the per capita amount Medicaid has to pay year to year, but which a per capita cap wouldn’t budget for.

For instance, the opioid epidemic has taxed state Medicaid programs as more patients need treatment for substance use disorder. Today, an increase in need leads to an automatic increase in federal funds flowing to states. But the Republican plan would halt that and put the whole burden on states. To try to make up for that, it adds a mostly symbolic $2 billion fund to address the opioid crisis, which almost certainly wouldn’t be enough to address this problem.

4) People in states that take a Medicaid “block grant,” who could see dramatic cuts in coverage

The BCRA also allows states to forgo the per capita cap and adopt an even more drastic reform if they want to: a full block grant. States would get a fixed pot of money for Medicaid over a 10-year period, increasing every year only with the normal inflation rate. There would be absolutely no allowance for increased population, or for increased need during recessions. States would be forced to raise taxes or restrict eligibility when federal funds inevitably prove inadequate. Seniors and people with disabilities would be exempted, but would inevitably be hurt as the program itself undergoes cuts.

Why would states choose to take this much less money from the feds? Because, as Edwin Park, Judith Solomon, and Hannah Katch at the Center on Budget and Policy Priorities explain, the block grant also provides states with "virtually unfettered flexibility to decide how to spend the federal funds they receive. … Under the block grant, states would no longer have to comply with most federal Medicaid requirements for children and adults. States could immediately cut eligibility and benefits to avoid any shortfalls and they would be allowed to carry over unused funds to the next year."

States would no longer be required to cover poor parents. They could charge unlimited premiums, deductibles, and copayments. They could impose enrollment caps and waiting lists, and they could cut the range of services provided to poor children.

"Over time, states electing the block grant would be forced to use this flexibility to make increasingly draconian cuts to their Medicaid programs, as the block grant funding cuts became increasingly severe," Park, Solomon, and Katch write.

5) People in states with above-average Medicaid spending

A new provision in the Senate bill, not in the House version, offers additional federal funding for states whose per-beneficiary spending on Medicaid in various categories comes in more than 25 percent below average, and reduces funding for states where it comes in more than 25 percent above average.

This change, flagged by Slate’s Jordan Weissmann, would affect a wide number of states. According to Kaiser Family Foundation data from 2014, that year 25 states (including DC) exceeded average national per-beneficiary spending in at least one category (whether on disabled people, seniors, adult, or children):

  • Arkansas
  • Connecticut
  • Delaware
  • District of Columbia
  • Georgia
  • Indiana
  • Iowa
  • Kansas
  • Maryland
  • Massachusetts
  • Minnesota
  • Missouri
  • Nebraska
  • New Hampshire
  • New Mexico
  • New York
  • Ohio
  • Oregon
  • Pennsylvania
  • Rhode Island
  • Tennessee
  • Vermont
  • Virginia
  • Washington
  • West Virginia

The bolded states exceed the mean by more than 25 percent in multiple categories. There's an exclusion for low-population-density states, which would exempt Alaska, Montana, North Dakota, South Dakota, and Wyoming from this provision. But the affected states still include many places with at least one Republican senator, and which Trump won, like West Virginia, Tennessee, Pennsylvania, Ohio, Nebraska, Missouri, Kansas, Iowa, Indiana, Georgia, and Arkansas.

These are both states that are unusually generous (like New York) and states that have higher-than-average health costs due to underlying poor health, like West Virginia, which struggles with coal-related health problems among other issues. Several states, like New Hampshire and Vermont, are heavily hit by the opioid epidemic. “States have higher spending for a number of reasons, many of which are outside of their control — like higher costs because of geography or less provider competition,” CBPP’s Katch notes.

What happens to these states? They get a cut of 0.5 percent to 2 percent in their per capita caps. Some years, Katch notes, that would totally wipe out the growth in caps due to inflation. The CPI often comes in lower than 2 percent, meaning that a state in a year with 2 percent inflation that got dinged 2 percent due to this provision would have to freeze spending.

The provision “just goes after higher cost states, blindly, it would appear,” according to Sara Rosenbaum, professor of health policy at George Washington University who serves on a board advising Congress on Medicaid policy. The bill, she elaborates, “pushes the highest-cost states to an arbitrary mean regardless of conditions on the ground that may be causing the state variations and then imposes an even more punishing growth cap over time.”

6) Pregnant women and new mothers

Like the House bill, the BCRA has a provision letting states waive essential health benefits, a key reform from the Affordable Care Act that required all insurers to cover 10 types of procedures and medical services:

  • Outpatient care without a hospital admission, known as ambulatory patient services
  • Emergency services
  • Hospitalization
  • Pregnancy, maternity, and newborn care
  • Mental health and substance use disorder services, including counseling and psychotherapy
  • Prescription drugs
  • Rehabilitative and habilitative services and devices, which help people with injuries and disabilities to recover
  • Laboratory services
  • Preventive care, wellness services, and chronic disease management
  • Pediatric services, including oral and vision care for children

“This means that plans in the individual market could once again decide not to cover maternity care — like 88 percent of plans did before the Affordable Care Act passed," as Vox's Sarah Kliff explains.

7) Low-income Americans not on Medicaid

The BCRA offers tax credits to buy health insurance that are markedly smaller than those in Obamacare, and which are used to cover less coverage. Under Obamacare, tax credits were tethered to the cost of plans covering 70 percent of medical expenses. The BCRA would reduce that amount to 58 percent. That means higher deductibles, copayments, and other cost-sharing devices to make up for lower premiums than a more generous plan would have.

That’s particularly bad news for the people being kicked off Medicaid, who would get tax credits but would be forced to use them to buy coverage that has cost sharing. Medicaid, by contrast, has minimal or no premiums, deductibles, or copays, depending on the state. It’s true that people in states that didn’t expand Medicaid would get tax credits where they currently get nothing, but the coverage they’d receive would be inferior compared with if their governors and legislatures had simply adopted the expansion.

Moreover, the changes to credits are also bad news for low-income people already on the exchanges, who would get smaller credits for worse coverage.

The CBO expects that because of these issues, few low-income people will even bother to use the tax credits to buy insurance. “The deductible for a plan with an actuarial value of 58 percent would be a significantly higher percentage of income,” the office writes; indeed it’d reach about $6,000 a year, or most of the income of a poor person. “As a result, despite being eligible for premium tax credits, few low-income people would purchase any plan, CBO and JCT estimate.”

8) Older people on the exchanges

But older people not yet old enough to qualify for Medicare who get their coverage individually by buying on Obamacare’s exchanges would also be out of luck. Under Obamacare, premiums are capped as a share of income, and the caps don't vary by age. Under the BCRA, the caps would vary by age. While a single person earning three times the poverty line ($35,640) pays no more than 9.69 percent of their income on premiums under Obamacare, under the BCRA the caps would vary from 6.4 percent for people under 30 to 16.2 percent for people over 59.

So for a 60-year-old at 300 percent of the poverty line, the maximum premium would go from $3,442 a year to $5,773, per Vox’s Sarah Kliff. And the plan would be less comprehensive, only being required to cover 58 percent of health costs, not 70 percent as under current law.

As another example, the CBO estimates that a 64 year old earning 375 percent of the poverty line ($56,800 in 2026) would have to pay $16,000 a year in premiums, for a $6,000 deductible. Their combined premiums and deductible could amount to nearly 40 percent of their annual income.

9) Children in special education programs

This is a less noticed element of the House and Senate bills, but many school districts rely on Medicaid to provide services to disabled students. Because of the cuts implied by the per capita cap and block grant provisions, AASA, a group representing school superintendents, is warning that school services for disabled children could be cut back or rationed as a result of the federal Medicaid cuts.

“"A per-capita cap, even one that is based on different groups of beneficiaries, will disproportionally harm children’s access to care, including services received at school," AASA’s Sasha Pudelski, along with the National Alliance for Medicaid in Education's John Hill and the National Association of School Psychologists' Kelly Vaillancourt Strobach, said in a statement. "Schools are often the hub of the community, and converting Medicaid’s financing structure to per-capita caps threatens to significantly reduce access to comprehensive health care for children with disabilities and those living in poverty."

10) Planned Parenthood patients

If you rely on a Planned Parenthood clinic for non-abortion services, such as birth control, pregnancy and STD tests, and cancer screenings like breast exams and Pap smears, the Better Care Reconciliation Act affects you as well. For at least one year, Planned Parenthood could no longer receive Medicaid reimbursements, even though it’s already barred from using federal Medicaid money to get abortion services.

In more than 100 counties across the country, Planned Parenthood is the only full-service birth control clinic, so denying the organization Medicaid funds would drastically reduce access to contraception and related services for people in those regions.

The most devastating passage in the CBO’s report on the Senate health bill
June 26th, 2017, 07:20 PM

The CBO says “few low-income people would purchase any plan” under GOP health bill.

The Congressional Budget Office has released its analysis of the Senate GOP’s Better Care Reconciliation Act, and it’s a bloodbath. The bill is expected to lead to 15 million fewer people with health insurance by 2018 — and 22 million fewer by 2026.

 Javier Zarracina/Vox

But the most devastating of the CBO’s conclusions can be found on page eight. There, the Congressional Budget Office says the BCRA would make decent insurance so expensive that “few low-income people would purchase any plan” at all. Here’s the section:

Under this legislation, starting in 2020, the premium for a silver plan would typically be a relatively high percentage of income for low-income people. The deductible for a plan with an actuarial value of 58 percent would be a significantly higher percentage of income — also making such a plan unattractive, but for a different reason. As a result, despite being eligible for premium tax credits, few low-income people would purchase any plan, CBO and JCT estimate.

A bit of background is helpful. A “silver plan” is an insurance plan that covers 70 percent of a person’s expected health care costs. Obamacare’s subsidies were designed to make silver plans affordable and to limit out-of-pocket costs. The BCRA cuts Obamacare’s subsidies and designs its own subsidies around plans that cover 58 percent of expected health care costs. Those plans, the CBO estimates, will come with deductibles of around $6,000 — which means they would bankrupt many poor people before they ever got through the deductible.

On page 27 of the report, CBO offers an illustrative example. Imagine, they say, a person who makes 75 percent of the poverty line and is currently on Medicaid. The deductible would be more than half their annual income. They would be paying for health insurance that they would destroy them financially if they tried to use it.

So here is what the CBO is saying: The BCRA’s subsidies are too small to make the silver plans affordable for low-income people, and the plans it is trying to make affordable — the ones that cover 58 percent of expected costs — carry such high deductibles that low-income Americans won’t buy them because they won’t be able to afford to use them.

This, then, is what the BRCA actually does: It makes health insurance unaffordable for poor people in order to finance a massive tax cut for rich people.

But there’s much more in the CBO report worth noting. A few points:

  • Remember when Donald Trump bragged that “I was the first & only potential GOP candidate to state there will be no cuts to Social Security, Medicare & Medicaid”? This BCRA’s savings come almost entirely from cuts to Medicaid. “Spending on the program would decline in 2026 by 26 percent” as compared to current law, CBO projects.
  • CBO directly rebuts Republicans who say this bill needs to pass because insurance markets are collapsing under Obamacare. Like under the Affordable Care Act, the agency projects individual insurance markets will mostly be stable, but in some areas of the country, “no insurers would participate in the nongroup market or insurance would be offered only with very high premiums.” Exactly what’s happening now, in other words.
  • While CBO doesn’t think the bill will lead to death spirals in most markets, it explains very clearly how the death spirals it does create will work. “Because the total subsidy per person under the legislation would be substantially smaller than under current law, the fraction of purchasers who are subsidized would fall. Among the unsubsidized population, less healthy people are more likely to purchase insurance—and the higher costs for them would put upward pressure on premiums. As unsubsidized people became a greater fraction of the purchasers, that pressure would be greater and could result in very high premiums in some markets.”
  • The increase in uninsurance under the BCRA “would be disproportionately larger among older people with lower income—particularly people between 50 and 64 years old with income of less than 200 percent of the federal poverty level.” A lot of the people in that demographic are Republican voters.
  • Congressional Republicans are leaning hard on the idea that their plan brings down premiums, but it actually doesn’t. “Under this legislation, the net premium for a plan with an actuarial value of 58 percent would be smaller for younger people and larger for older people, but the net premium for a plan with an actuarial value of 70 percent would be larger for people of any age,” CBO says. In other words, premiums on decent insurance are higher for everyone, and premiums on high-deductible plans are a bit lower for the young at the cost of making them higher for the old.
2 winners and 4 losers from the Senate health care bill
June 26th, 2017, 07:20 PM

The Better Care Reconciliation Act, Senate Republicans’ plan to repeal and replace Obamacare, would if passed lead to one of the largest redistributions of income in American history, just as Obamacare itself did.

It would shift hundreds of billions of dollars from health care programs to fund sweeping tax cuts for rich Americans, radically overhaul the way the US supports elderly and disabled people, and allow states to substantially weaken insurance regulations. While it clearly does not yet have the votes it needs to pass the Senate, it could still be tweaked and make it through, and if it does, it will have a strong chance of becoming law.

Here’s who stands to gain if that happens, and who stands to lose.

Loser: America’s working poor

Of the 22 million people the Congressional Budget Office projects will lose coverage under the bill, 15 million are currently covered by Medicaid, which the Senate bill would slashed by about $774 billion over 10 years. The cuts will grow even further after the 10 year window is up, because the bill ties Medicaid funding to a slow-growing inflation measure.

These are the poorest and most vulnerable people who’ll lose insurance under the bill.

In the 31 states (and Washington, DC) that expanded Medicaid following the Affordable Care Act, all adults earning up to 138 percent of the poverty line are eligible for Medicaid. Non-expansion states often feature much lower income thresholds to qualify for Medicaid, particularly for non-parents. The Affordable Care Act’s expansion, where it was adopted, effectively turned Medicaid into a universal insurance guarantee for people in poverty, whereas many people fell between the cracks before.

The BCRA would effectively end the Medicaid expansion starting in 2021. Under current law, the federal government initially paid 100 percent of costs of Medicaid expansion beneficiaries, a percentage set to wind down to 90 percent in 2020 and stay at that level permanently. Under the Senate bill, the federal government would gradually wind down that percentage to the states’ normal matching rates for Medicaid — rates that are as low as 50 percent in certain states.

The Congressional Budget Office has argued that this will mean no more states pursue expansion. It will also spark states with “trigger laws” — which end the expansion if there’s any reduction in the federal match — to automatically abandon it starting in 2021. Those states are Arkansas, Arizona, Illinois, Indiana, Michigan, New Hampshire, New Mexico, and Washington.

Joan Alker, a Medicaid expert at Georgetown University, estimates that those eight states alone could lead to 3.3 million Medicaid enrollees losing coverage. But many of the other 24 states will abandon the expansion due to the lower match rate as well. And keeping it going will be even harder due to other, fundamental changes the bill makes to the Medicaid program.

Replacing Medicaid expansion for poor people are new tax credits that are much less generous than those under current law. Under Obamacare, tax credits were tethered to the cost of plans covering 70 percent of medical expenses. The BCRA would reduce that amount to plans that cover 58 percent. That means higher deductibles, copayments, and other means of cost sharing to make up for lower premiums than a more generous plan would have.

That’s particularly bad news for the people being kicked off Medicaid, who would get tax credits but would be forced to use them to buy coverage that could cost them thousands of additional dollars per year. Medicaid, by contrast, has minimal or no premiums, deductibles, or copays, depending on the state. It’s true that people in states that didn’t expand Medicaid would get tax credits where they currently get nothing, but the coverage they’d receive would be dramatically inferior compared with if their governors and legislatures had simply adopted the expansion.

Moreover, the changes to credits are also bad news for low-income people already on the exchanges, who would get smaller credits for worse coverage.

The CBO expects that because of these issues, few low-income people will even bother to use the tax credits to buy insurance. “The deductible for a plan with an actuarial value of 58 percent would be a significantly higher percentage of income,” the office writes. “As a result, despite being eligible for premium tax credits, few low-income people would purchase any plan, CBO and JCT estimate.”

Loser: disabled people, elderly people, and everyone else who relies on Medicaid

GOP Senators Hold Meeting To Discuss Draft Of Healthcare Bill Mark Wilson/Getty Images
Capitol Police remove a woman participating in a disability rights protest in front of Senate Majority Leader Mitch McConnell’s office.

it’s not just people who gained coverage under Obamacare’s Medicaid expansion who would lose out. The law would also adopt a policy known as a “per capita cap” for Medicaid that would hurt all beneficiaries.

Currently, the federal government matches state spending on Medicaid, offering about $1 to $2.79 for every dollar states spend on it. Poorer states get a bigger match. But the BCRA would change all that.

The AHCA would cap the state match at a set amount of money per person. Until 2025, the amount would grow from year to year according to the medical component of the Consumer Price Index, to account for inflation. Then it would switch to the overall CPI.

The medical component of CPI is growing more slowly than Medicaid costs are expected to grow right now, according to the Center on Budget and Policy Priorities, and the CPI as a whole grows far more slowly. So switching to a per capita cap and tying increases to CPI is essentially a federal cut to Medicaid amounting to hundreds of billions over 10 years. In total, the CBO finds that the bill cuts Medicaid by $774 billion over ten years — and by much more over a longer time horizon.

A per capita cap is at least somewhat responsive to changes in Medicaid enrollment — unlike a block grant, which gives states a set amount of money, it gives them a set amount of money for every person who’s eligible. But it could lead to cuts in some other ways as well. Take a state like Florida that’s aging fast. The BCRA includes separate caps for different groups of beneficiaries — the elderly, disabled, non-elderly adults, etc. — so states can’t get more money by dumping lots of seniors in favor of 24-year-olds.

However, there is still a lot of variation in cost within those categories. “Within your elderly group, you have the young and old, 67-year-olds and 85-year-olds, and the latter are much more expensive,” Georgetown’s Alker told me in March. A state like Florida, which has a large senior population, could see costs rise fast as its population ages with time. But a per capita cap wouldn’t keep up with that. To get around that, the state might be motivated to kick off older seniors and focus enrollment on younger ones.

There are some federal requirements as to whom states must cover, but they only go so far, and most states now provide additional coverage that they can roll back. “You do have to cover people on Supplemental Security Income” — a program for disabled, elderly, and blind people with low incomes — ”but a lot of folks in nursing homes [are] optional coverage,” Alker continued.

This helps explain why disability rights activists are appalled by the per capita cap plan, and have been aggressively protesting the Senate and House bills; about 50 disabled people, many in wheelchairs, were arrested for protesting outside Senate Majority Leader Mitch McConnell’s office.

“People with disabilities who rely on home- and community-based services through Medicaid — such as personal-attendant care, skilled nursing, and specialized therapies — could lose access to the services they need in order to live independently and remain in their homes,” the Center for American Progress’s Rebecca Vallas, Katherine Gallagher Robbins, and Jackie Odum note.

As if that weren’t enough, the bill has also been changed to allow states to impose work requirements on Medicaid, a policy that would not effectively spur people to work or reduce poverty but that could meaningfully reduce access to care for poor families, and which even many conservative health care experts oppose.

Loser: people in states that take a Medicaid “block grant,” who could see dramatic cuts in coverage

The BCRA also allows states to forgo the per capita cap and adopt an even more drastic reform if they want to: a full block grant. States would get a fixed pot of money for Medicaid over a 10-year period, increasing every year only with the normal inflation rate. There would be absolutely no allowance for increased population, or for increased need during recessions. States would be forced to raise taxes or restrict eligibility when federal funds inevitably prove inadequate. Seniors and people with disabilities would be exempted, but would inevitably be hurt as the program itself undergoes cuts.

Why would states choose to take this much less money from the feds? Because, as Edwin Park, Judith Solomon, and Hannah Katch at the Center on Budget and Policy Priorities explain, the block grant also provides states with "virtually unfettered flexibility to decide how to spend the federal funds they receive. … Under the block grant, states would no longer have to comply with most federal Medicaid requirements for children and adults. States could immediately cut eligibility and benefits to avoid any shortfalls and they would be allowed to carry over unused funds to the next year."

States would no longer be required to cover poor parents. They could charge unlimited premiums, deductibles, and copayments. They could impose enrollment caps and waiting lists, and they could cut the range of services provided to poor children.

"Over time, states electing the block grant would be forced to use this flexibility to make increasingly draconian cuts to their Medicaid programs, as the block grant funding cuts became increasingly severe," Park, Solomon, and Katch write.

Loser: pregnant women and new mothers

A pregnant woman RJ Sangosti/The Denver Post via Getty Images

Like the House bill, the BCRA has a provision letting states waive essential health benefits, a key reform from the Affordable Care Act that required all insurers to cover 10 types of procedures and medical services:

  • Outpatient care without a hospital admission, known as ambulatory patient services
  • Emergency services
  • Hospitalization
  • Pregnancy, maternity, and newborn care
  • Mental health and substance use disorder services, including counseling and psychotherapy
  • Prescription drugs
  • Rehabilitative and habilitative services and devices, which help people with injuries and disabilities to recover
  • Laboratory services
  • Preventive care, wellness services, and chronic disease management
  • Pediatric services, including oral and vision care for children

“This means that plans in the individual market could once again decide not to cover maternity care — like 88 percent of plans did before the Affordable Care Act passed," as Vox's Sarah Kliff explains.

Poor women (and men, for that matter) who rely on Planned Parenthood for health services are also out of luck. If you rely on a Planned Parenthood clinic for non-abortion services, such as birth control, pregnancy and STD tests, and cancer screenings like breast exams and Pap smears, the Better Care Reconciliation Act affects you as well. For at least one year, Planned Parenthood could no longer receive Medicaid reimbursements, even though it’s already barred from using federal Medicaid money to get abortion services.

In more than 100 counties across the country, Planned Parenthood is the only full-service birth control clinic, so denying the organization Medicaid funds would drastically reduce access to contraception and related services for people in those regions.

Winner: the wealthy

So who gains from all this coverage loss, all the Medicaid cuts, and all these stingier private plans? Mainly, rich people.

The Affordable Care Act was financed by a diverse array of tax increases, mostly targeting high earners. The single biggest tax cut included in the bill is the repeal of the 3.8 percent tax the Affordable Care Act applied to capital gains, dividend, and interest income for families with $250,000 or more in income ($125,000 for singles).

Repealing that tax is a change that, by definition, only helps the rich, or at least the affluent. If you’re part of a married couple and, like the vast majority of Americans, make less than $250,000 a year, or earn more than that but have little investment income, it doesn’t affect you at all. The Tax Policy Center finds that repealing the tax would amount to an average tax cut of $0 for households in the bottom 90 percent — those making $208,500 or below. A handful of people in the 80th to 95th percentiles would see cuts, but the vast majority wouldn’t.

By contrast, members of the top 0.1 percent, who each on average make more than $3.75 million annually, would get an average tax cut of $165,090.

Then there’s the 0.9 percent Medicare surtax, a hike on wage income in excess of $250,000 a year ($200,000 for unmarried people). The Republican bill would repeal this surtax and, in so doing, give everyone in the bottom 90 percent an average tax cut of $0, per the Tax Policy Center. The richest of the rich, the top 0.1 percent, would get an average cut of $30,520.

We don’t have a full distributional analysis of the Republican bill yet. But the Medicare surtax and the investment tax alone combine to a tax cut of $195,610 for the top 0.1 percent, not far off from the $197,340 average cut estimated for full repeal of Obamacare. It’s hard to overstate what a massive windfall this is for the richest Americans:

Winner: pharma, medical device manufacturers, tanning salons, and more

But Obamacare did not merely raise taxes on the rich. It raised taxes on a variety of health care–related businesses as well. The biggest hike was a fee on health insurance companies. Which Americans are affected by this fee right now is less clear; insurers have said they’re passing on the cost to consumers in the form of higher premiums, but exactly which premiums are raised and whether insurers actually eat some of it isn’t totally clear.

Whether the insurance industry will come out ahead or behind from this bill is a bit unclear. On the one hand, it allows states to loosen regulations that insurers loathe, and includes billions of dollars for insurers to get them to stabilize individual insurance marketplaces. However, there’s a real danger that by repealing the individual mandate, the law will cause a death spiral in the individual market with devastating effects for consumers, insurers, and just about everybody else.

But you know who will definitely come out ahead? Medical device manufacturers. These companies, which make things like X-ray and MRI machines and pacemakers (devices sold via retail, like hearing aids, are exempt), have been paying a medical device excise tax as part of Obamacare, and they hate it. Senators from states with large medical device industries, including otherwise liberal members like Elizabeth Warren and Al Franken, have been pushing to repeal the tax for years. If this bill succeeds, they’ll finally see the tax go away for good.

So will tanning salons, which have faced a tax on their equipment due to the health risks associated with the practice. The tax served a worthwhile purpose; as many as 400,000 cases of skin cancer every year are caused by tanning, But the industry has been lobbying against the measure since before Obamacare was enacted, and will get a big win should the BCRA pass.

Meanwhile, pharmaceuticals will enjoy the repeal of a tax on brand-name drugs. Like the medical device and tanning taxes, it raises a pretty modest amount of money (about $20 billion over 10 years) compared with the taxes on rich individuals, but it’s a major irritant to a powerful industry that the BCRA will quickly eliminate.


The Senate health bill: poor people pay more for worse insurance

Behold the Dreamers is a damning examination of the modern American dream
June 26th, 2017, 07:20 PM

Halfway through Behold the Dreamers, Imbolo Mbue’s lush and lovely debut novel, Neni Jonga finds her employer, Cindy Edwards, unconscious on a bed, surrounded by pill bottles and an empty wineglass.

Neni is a Cameroonian immigrant, an aspiring pharmacist who’s earning some extra money by working as a temporary housekeeper for a wealthy family that also employs her husband as a chauffeur. It’s 2008, and Mr. Edwards works for Lehman Brothers, so things are tense. Still, Neni can’t imagine why Cindy — wealthy, beautiful Cindy — would need to take drugs.

Rating


4

She isn’t sure what to do. If she touches Cindy and then Cindy dies, will she be blamed? But if Cindy dies because Neni did nothing, won’t Neni also be to blame? She’s only barely documented; any trouble could get her deported.

So she wakes Cindy up, carries her out of bed, feeds her, and bathes her. The next day, she listens with compassion as Cindy explains her tragic backstory, how she grew up with nothing:

"I came from a poor family. A very, very poor family."

"Me, too, madam — "

Cindy shook her head. "No, you don’t understand," she said. "Being poor for you in Africa is fine. Most of you are poor over there. The shame of it, it’s not as bad for you."

Neni closed her eyes and nodded as if she completely understood and agreed.

It never occurs to Cindy to ask Neni about what her life is like, and Neni certainly doesn’t volunteer details. Their relationship is not reciprocal; it is transactional. But Neni is doing a lot more than Cindy is paying her to do.

The soul of this book is rooted in the complex relationship between employer and employee

The labor that Neni performs for Cindy in the above scene is not only physical; it is emotional. She’s asked not just to keep Cindy’s opulent Hamptons home spotless but also to take on Cindy’s psychological baggage, to soothe her and tend to her, to ignore her own interests and dignity in order to preserve her employer’s.

This is the slippage that lies at the heart of the impressive Behold the Dreamers: how easily the physical labor the Edwardses demand of the Jongas blurs into emotional labor.

So as Neni covers for Cindy’s ever-more-frequent drinking sprees, her husband Jende drives Clark Edwards to seedy hotel trysts with escorts. When Cindy asks him if Clark is cheating on her, he lies. He learns of Clark’s doubts about the worthiness of his work and his confused estrangement from his children. He acts as a kind of confessor in the front seat of the car, absolving Clark of his sins.

By the end of Behold the Dreamers, as Wall Street goes up in flames, it’s clear the Edwardses have outsourced all of their emotional labor to their household staff, and it’s taken a toll on the Jongas.

Behold the Dreamers reveals the dark side of the American dream

The toxic relationship between the Jongas and the Edwardses reveals itself slowly, almost imperceptibly. The Jongas are jubilant at the start of the novel, when Jende lies his way into the chauffeur job for the princely salary of $30,000 a year: At last, they say, they can start to save for a house! And then Neni can finish school and become a pharmacist, and their children will reap all the benefits of an American education, and they’ll truly be living the American dream.

But as they spend more time with the Edwardses, Jende and Neni begin to argue more and more. Jende starts telling Neni she’s stupid; Neni starts to hide things from Jende. She even begins to fear that he’ll beat her — but if he does, she thinks, she’ll know it wasn’t really him but "a grotesque being created by the sufferings of an American immigrant life."

It’s not all grotesque suffering, though. Mbue finds room in Behold the Dreamers to highlight moments of intense joy in the Jongas’ life: They feast on fried plantains and cocoyams and smoked turkey neck; they glory in Columbus Circle — "the center of the world"; and they dance ecstatically at a house party:

They jumped and skipped as they pumped their fists, shouting together as loud as they could, Blazo, blazo, zoblazo, on a gagné! On a gangné! When one of Jende’s non-African friends from work asked him what the song meant, he shouted, without pausing to catch his breath, it means we have won, man. It means we have won!

But as joyous as the moment is, it also invites the difficult question: What have they won? Was it just the opportunity to work for selfish wealthy people who unthinkingly suck the life out of them? Is that, ultimately, all the American dream has to offer the Jongas? And if it is, Behold the Dreamers asks, is it a dream worth dreaming?

CBO: Senate health bill doesn’t help the poor in non-Medicaid states
June 26th, 2017, 07:20 PM

A $6,000 deductible isn’t much help if you’re earning $12,000 a year.

Over the past several years, health care for the American poor has become a curious patchwork where most blue and purple states expanded Medicaid but the solidly red ones — especially in the South — generally did not.

When congressional Democrats drafted the Affordable Care Act back in 2009 and 2010, they took it for granted that all states would accept federal funding to expand their Medicaid programs. But then the Supreme Court ruled that a key element of the law, which essentially forced states to do that, was unconstitutional. This created a weird and unenvisioned gap in the law’s coverage provisions.

If your income is slightly too high to qualify for Medicaid, you receive a pretty generous subsidy to buy health insurance on your state’s exchange. But if you are just below the threshold and you live in a state like Texas or Florida that hasn’t expanded Medicaid, then you get nothing at all.

The Senate’s health bill, while drastically cutting Medicaid, does address this “Medicaid gap” issue by making subsidies available all the way down the income chain. Texas-based journalist Erica Grieder argues this makes the bill a good deal for low-income people in those states.

The reality is not so clear. According to the Congressional Budget Office score of the plan, “despite being eligible for premium tax credits, few low-income people would purchase any plan,” because the plans available are essentially useless to the poor.

Many patients using ACA exchange plans complained that they had deductibles so high that the insurance was hardly worth using. The law did, however, attempt to address that by offering special additional subsidies to limit out-of-pocket costs to the lowest-income patients. It also required insurance companies to cover preventive medicine with no copayment or deductible. The Senate bill changes all of this, and creates a situation where even with subsidy, a typical person poor enough to qualify for Medicaid is probably worse off buying insurance.

BCRA will create extremely high deductible plans

Under Obamacare, tax credits were tethered to the cost of plans covering 70 percent of medical expenses. The Better Care Reconciliation Act would reduce that amount to plans that cover 58 percent — meaning higher copayments and deductibles.

It also allows states to waive out of the “essential health benefits” requirements that cover preventative care and other things. Many states, of course, won’t waive those requirements. But since we’re talking about non-expansion states, we are already specifically talking about the states with the most rigorously conservative politicians, so they probably will waive them.

The result is that you’re talking about plans that likely won’t cover any services without cost sharing, and whose deductibles are likely to be in the range of $6,000 or more.

The people currently ineligible for subsidies are people earning 100 percent of the federal poverty level or less. For a single individual, that means less than $12,060 a year. Even if the subsidized cost of your premium was very low, it’s difficult to see what the actual value of a plan with a deductible that high would be. You’re going to end up indigent and relying on emergency room care well before you hit that level.

Of course, it’s possible in theory to have very low income and also have $15,000 stashed away in the bank. But according to the Federal Reserve’s Survey of Consumer Finances, the bottom 25 percent of the population had a median net worth of $50 back in 2013. When the data is updated later this year, it will probably show a modest increase. But outside of a handful of weird edge cases, there’s just no way people with incomes below 100 percent of the poverty line can afford to use the kind of high-deductible plans the BCRA envisions.

The Congressional Budget Office, explained
June 26th, 2017, 07:20 PM

CBO’s score of Republicans’ health plan is out, and it looks grim. Here’s why the agency has such influence.

Congress votes on bills, and the president signs them. And yet, to hear some tell it, it’s an entirely different institution that really calls the shots in Washington.

“I say all the time that CBO is God around here,” Sen. Chuck Grassley (R-IA) mused back in 2006. “Because policy lives and dies by CBO’s word.”

Indeed, in the four decades since its creation, the nonpartisan Congressional Budget Office has carved out an institutional role for itself as the well-respected arbiter not only of how much proposed legislation in Congress would cost but also what its economic effects would likely be.

CBO has no formal power over anything, and it never takes an explicit position for or against any bill. But despite — or perhaps because of — those facts, its estimates have been so influential among the political class that Sen. Ron Wyden (D-OR) could say in 2008, “The history of health reform is congressmen sending health legislation off to the Congressional Budget Office to die.”

Now it’s the fate of Republicans’ attempt to repeal and replace Obamacare that could well be determined by CBO’s pronouncements. On Monday, CBO released a report estimating the effects of the Senate health care bill, and they look grim — the office projected that if the bill became law, 22 million fewer people would be insured by 2026.

It’s possible that this could cause swing vote senators to turn against the bill en masse, or force major changes to it. Sen. Dean Heller (R-NV) has already said that he opposes the current version of the bill because it causes “tens of millions” of people to lose coverage, and another moderate holdout, Sen. Susan Collins (R-ME) has told reporters that she was waiting to hear what the CBO score would be. However, Senate Majority Leader Mitch McConnell also has to avoid losing too many votes from the right.

Perhaps anticipating a grim CBO assessment, Trump administration officials have preemptively tried to discredit the office. “They were way, way off the last time,” press secretary Sean Spicer said in March. “If you’re looking at the CBO for accuracy, you’re looking in the wrong place.” (Per the Commonwealth Fund, CBO overestimated how many people would sign up for Obamacare’s exchanges, but its projections were closer to reality than those of “many other prominent forecasters.”)

The budget office has never claimed to be able to perfectly predict the future. Instead, former director Robert Reischauer tells me that in a world full of politically motivated projections, “CBO’s function is to provide a dose of reality.” And now, faced with an administration that often advances “alternative facts,” it could face its greatest challenge yet.

1) What is the Congressional Budget Office?

On paper, the CBO is a number-crunching agency with the unglamorous task of helping members of Congress estimate just how much their fun-sounding new bills would actually cost, and writing reports on federal spending.

But in practice, it has evolved into something much more powerful. Some call it Washington’s scorekeeper, umpire, or referee. Others view it, effectively, as a political power center in its own right, since politicians often reshape (or abandon) proposed legislation as a result of CBO’s pronouncements.

The CBO is run by a director, who is appointed by Congress and serves a four-year term. The current director, Keith Hall, was picked by House Republicans (including then-Budget Committee chair and now HHS Secretary Tom Price) in 2015. Beneath the director is a staff of about 230, most of whom, the agency says, “are economists or public policy analysts with advanced degrees.”

Over the office’s four-decade existence, a distinct culture has been instilled in those employees. It’s in part a culture of wonky analysis. “Most people are there as researchers,” says Jonathan Schwabish, who worked at CBO from 2005 to 2014. “As researchers your DNA is to approach the world and say, ‘There’s a question that I want to answer, or get as close to the truth as I can.’”

But CBO’s culture isn’t an ivory tower one. Since it’s tasked with communicating with members of Congress, it’s also tried to focus on making its analyses accessible. “We should break with the ponderous prose of most official economic writing and aim at giving Congressmen themselves something they can actually read and understand,” CBO’s first director, Alice Rivlin, wrote in 1975.

CBO also has a culture of skepticism. Doug Holtz-Eakin, who was director from 2003 to 2005, once said: “Every advocate comes to CBO and their null hypothesis is that they are right and they think CBO’s null hypothesis is that CBO is right. But that’s not CBO’s null. CBO’s null is you’re wrong.” That quote comes from University of Maryland public policy professor Philip Joyce’s excellent book The Congressional Budget Office: Honest Numbers, Power, and Policy, and Joyce elaborated on it to me: “It’s the same bias shared by all good budget offices, they think people coming to them with a proposal to do anything are looking for a free lunch.”

Finally, CBO’s culture prizes ignoring political pressure — even if that pressure comes from the director’s own political party. The office’s staff style themselves as not just telling political leaders what they want to hear. “CBO is an island of nonpartisanship in a roiling congressional sea of partisanship,” says Doug Elmendorf, director from 2009 to 2015.

2) Why is CBO so influential?

 Melina Mara/The Washington Post via Getty
Whether for substantive or political reasons, moderate senators like Susan Collins of Maine watch CBO scores closely.

CBO’s influence stems entirely from its credibility and reputation as a politically neutral arbiter. And that reputation is strongest among two very important groups of people who have come to take CBO’s projections extremely seriously: swing vote politicians, and the media.

Swing vote politicians are often looking to burnish a moderate image. So they try to determine whether particular bills are too budget-busting or extreme to support — either for substantive or political reasons. Indeed, because the swing vote Congress members and senators glom onto CBO, party leaders are frequently forced to rework their bills in hopes of getting better results from the office.

For example: Back when health reform was debated in 2009, a group of red-state Democratic senators were adamant that the 10-year cost of the bill be less than $1 trillion. Whether they were genuinely concerned about overspending, or they just feared political attacks on them for supporting a “trillion-dollar health care bill,” the important thing for our purposes is that they were focused CBO’s score as their metric.

The second source of CBO’s influence is its reputation in the mainstream media, which treats its estimates as essentially the gold standard. “The media has a tendency to play up the information coming out of CBO because they believe it to be objective and nonpartisan,” Joyce says. “They believe their numbers are less biased than numbers coming out of, for example, the executive branch.”

More partisan politicians and outlets, naturally, may not have such a fair-minded interest in CBO. But even they have a use for its estimates: as ammo against their political opponents. President Trump, for instance, repeatedly cited CBO to attack Obamacare before the election. “Both sides use CBO — and I mean use — in whatever sense they can,” says Holtz-Eakin.

3) Why does CBO exist?

 Tom Williams/CQ Roll Call/Getty
Alice Rivlin, CBO’s first director, testifies before a congressional committee in 2013.

The background for CBO’s creation lies in conflict between President Richard Nixon and Congress, which was then controlled by Democrats. Nixon had been “impounding” (refusing to spend) money Congress had appropriated for particular projects, including the Clean Water Act. This naturally made Congress quite unhappy, so legislators drew up a bill that would ban this practice.

Since they were tackling spending reform anyway, lawmakers decided they might as well tackle what they saw as a bigger related problem: Congress’s growing weakness in a budgeting process increasingly steered by the White House.

Though the Constitution gave Congress power over spending, the federal government had grown big and complex, and Congress hadn’t kept up. So legislators decided to modernize the budgeting process in a way they hoped would make themselves players again.

Nixon was embattled by the Watergate scandal and unable to effectively push back, so in the end, the Congressional Budget and Impoundment Control Act of 1974 passed with huge majorities. The new law created the House and Senate Budget Committees and the modern budget resolution (and reconciliation) process.

It also, almost as an afterthought, created the CBO — Congress’s own budget office, envisioned as a counterpart to the White House’s Office of Management and Budget (OMB). The rationale was that Congress was sick of relying on the White House budget office’s projections, and viewed them as frequently biased, either for institutional or partisan reasons. So members seem to have decided, well, why not get our own?

But the CBO we know today was truly defined by its first director, Rivlin. As Joyce’s book recounts, Rivlin made a strategic decision to build CBO into a truly nonpartisan and analytically credible agency, rather than one that would carry Congress’s water in its squabbles with the White House or openly advocate for certain bills. To this end, Rivlin decided to make CBO an agency that would work for all of Congress — not just the budget committee chairs or the leaders of the majority party — which carved out space for her to act more independently.

Finally, though she was appointed by Democrats, Rivlin proved herself willing to challenge President Jimmy Carter’s White House, issuing harsh estimates about his energy plan’s effects. “Whenever you have budgeteers playing against partisan type it’s going to help send a signal about neutrality or objectivity,” says Sarah Binder, a congressional procedure expert at George Washington University.

4) How does CBO do its estimates?

Essentially, the office has built up a series of economic models that it’s used over the years, and it continues to tinker with them or build new models based on what’s on the agenda in Washington.

Each major score or forecast, Holtz-Eakin says, is “a team research project. There are people doing it, checking it, trying to make sure the research is covering the right thing, and people trying to make sure the research is understandable and defensible.”

Elmendorf estimates that about 40 people worked on CBO’s health reform analyses in 2009. “People come to meetings and say here are the papers we’ve read, here’s how we’re interpreting them, here’s how we’re putting them into the model to reflect that. There’s a discussion around the table where the director is one participant. I myself wouldn’t know the bottom line on estimates until the very end.”

Schwabish, the former CBO staffer, has a similar account: “You try to make the best model that we can, you run the model, and the chips fall where they may.”

Asked to provide more detail on how CBO modeled health reform proposals, Elmendorf elaborated:

CBO has spent the last 15 years building and improving models of health insurance in this country. Those models are based on empirical evidence about the way businesses and individuals respond to incentives regarding health insurance. The models are based on discussions by CBO analysts with the outside advisers that CBO gathers. The models are based on careful use of big data sets. And ultimately on judgment. There is no perfect model of the world.

5) How has CBO dealt with political criticism?

 Douglas Graham/Congressional Quarterly/Getty
Then-Speaker Newt Gingrich in his office at the Capitol in 1998.

CBO has a long and storied tradition of making it more difficult for political leaders to get what they want, by arguing that their rosy estimates are a little too rosy. And sometimes those political leaders don’t like that very much.

  • In 1981, President Reagan called Rivlin’s CBO numbers “phony” because they differed from his own OMB’s extremely optimistic projections about the deficit.
  • In 1995, Speaker Newt Gingrich repeatedly complained that the Republican-appointed CBO director, June O’Neill, wasn’t properly accounting for the benefits of tax cuts. “Every few weeks he would say that he was firing me, and I would be called in,” says O’Neill. “In his office he had a huge dinosaur [head], which makes it look scary when you walk in. But every time I actually went to see him, he would be very cordial.”
  • In 2002, House Budget Chair Jim Nussle said, “The CBO sucks, and you can quote me on that,” because he didn’t like a score of a farm bill.

But perhaps the most pressure ever put on a CBO director came during the health reform fight under President Bill Clinton. According to Haynes Johnson and David Broder’s book The System, CBO Director Robert Reischauer was intensely and often angrily lobbied by top Democrats to make scoring decisions that they hoped could help Clinton’s health bill. He was told that his intransigence would lead to many deaths if health reform failed, as well as the destruction of the Clinton presidency.

Reischauer didn’t budge in the end, and his eventual CBO report, which found that the Clinton plan would add $70 billion to the deficit over five years, was blamed by some Clinton allies for sinking the entire effort. “You’re under a lot of pressure, there’s no question about that,” Reischauer told me. “People have strong views. They express them to you privately, and if you don’t have the hide of a rhinoceros, you would not sleep at night and be in pretty bad shape.”

Yet Elmendorf professes not to have had the same experience during the Obamacare fight. “I didn’t feel much pressure that year to come up with different answers, from anyone,” he says. “I knew that members of Congress desperately wanted all sorts of answers from us. But I knew what my job was. I knew what my colleagues and I had to do, which was produce our best objective analysis.”

Indeed, what ended up happening was that rather than spending their time pressuring Elmendorf directly, congressional Democrats spent their time reworking their bill so that it would get a better score. They found it easier to completely rework a major piece of legislation — again and again — than to twist the CBO director’s arm.

This article was originally published in March. It has been updated to reflect recent developments.

Read: CBO score projects 22 million to lose coverage under Senate Republicans' health care bill
June 26th, 2017, 07:20 PM

According to a highly anticipated report from the Congressional Budget Office, the GOP Senate health care bill would cause 22 million people to lose coverage by 2026. The government would save $321 billion over the next ten years.

The CBO’s analysis of the Senate bill, called the Better Care Reconciliation Act, will have important implications for its passage. The number of Americans who would lose coverage could be critical to whether moderate senators vote for the bill. As Vox’s Dylan Scott wrote, based on these numbers, the Senate parliamentarian could decide whether the bill runs afoul of the Byrd Rule, which prohibits regulatory changes “extraneous” to the budget process from being passed through reconciliation on a simple majority vote.

As a general rule, regulatory changes would likely not be permissible under the Byrd Rule, as he said. Especially if no states took those waivers — as some moderate House Republicans suggested — then there would be no budgetary impact, and the provision would likely be struck.

But if the CBO concludes that a number of states would take the waivers, and the resulting impact on the federal budget is sizable enough, the parliamentarian may be able to justify the waivers under the Byrd Rule. The bill does make a specific pot of money, $8 billion, available only to states that seek waivers.

“It’ll come down unfortunately to CBO, when they put out the cost estimate on that bill,” Hoagland said. “Is it big or is it small?”

The CBO is a nonpartisan budget agency that projects how bills would affect the country. You can read the full text of the Congressional Budget Office cost estimate here, or below.

Mr. President, this health care bill is still mean
June 26th, 2017, 07:20 PM

Publicly, President Donald Trump has been a great defender of Congress's efforts to repeal and replace Obamacare, throwing a massive celebration on May 4 when the House passed its bill. But in private, he told Republican senators that the House bill was "mean," and that they would need to improve it greatly.

Trump has since confirmed he attacked the bill in private, and took a snipe at former President Barack Obama for criticizing repeal efforts in similar terms. “He used my term: 'mean,'" Trump said on Fox & Friends. "That was my term, because I want to see — and I speak from the heart — that’s what I want to see. I want to see a bill with heart."

Well, we have a Senate bill now. Two, in fact: the original version released on Thursday, and the amended version, with new incentives for young, healthy people to remain insured, unveiled on Monday along with a Congressional Budget Office analysis.

And both are them are clearly, unequivocally, mean. The Senate bill will take insurance away from tens of millions of people, make low-income Americans pay more in premiums and deductibles, and institute the biggest cut to Medicaid in American history. People will suffer. Some people will die.

According to the CBO, 22 million fewer people will have health insurance as a result of the Senate bill, in its latest form. And 15 million fewer will have Medicaid coverage, as the program is dramatically shrunk to below even its pre-Obamacare funding levels. Spending on health insurance for low- and moderate-income people will fall by $1 trillion over 10 years, of which $772 billion are cuts to Medicaid alone.

The best evidence we have on the effect of health insurance on human mortality suggests that taking insurance away from 22 million people will lead to more than 26,500 excess deaths every year. That’s, as my colleague Julia Belluz notes, “more than the death tolls from firearm homicides, HIV, and skin cancer in the US each year.” Tens or hundreds of thousands more will face medical bankruptcies, a trend that plummeted in dramatic fashion after Obamacare’s passage.

The Senate bill would make the working poor less economically secure

The cuts to Medicaid will hit people who qualified for the program even before Obamacare. Per-person spending on disabled people, elderly people, parents, and other categories of beneficiaries will be capped. States will have an incentive to shift costs, for example by enrolling more 67-year-olds and fewer 85-year-olds. Many could lose nursing home care, a popular form of optional coverage that would be one of the easiest areas to cut once the caps start straining states' budgets.

States could also choose to accept a flat “block grant,” which would sweep away most coverage requirements and not adjust money for population growth. With the block grant, states could immediately cut back on Medicaid eligibility and make benefits stingier, kicking thousands off the rolls and offering worse health care to those who remained. They wouldn't be required to cover poor parents, and could charge unlimited premiums, deductibles, and copayments. They could impose enrollment caps and waiting lists, and they could cut the range of services provided to poor children.

In the place of Medicaid, poor people will have access to high-deductible insurance. People in states that didn’t expand Medicaid right now have nothing, so any insurance is likely better than no insurance, but it's pretty rough.

Under Obamacare, tax credits were tethered to the cost of plans covering 70 percent of medical expenses. The Better Care Reconciliation Act would reduce that amount to 58 percent. That means higher deductibles, copayments, and other cost-sharing devices to make up for lower premiums than a more generous plan like Medicaid would have.

“Somebody making $20,000 a year could easily see deductibles increase dramatically, from $1,000 … up to … $6,300,” Huffington Post’s Jonathan Cohn notes. In other words, that person could spend nearly one-third of their annual income on health care costs before their insurance chipped in to help cover them. And those currently on the exchanges would also get this worse, less comprehensive coverage.

The Senate bill could hurt mothers, old people, and children with disabilities

Mothers and pregnant women could also be worse off. The Senate and House bills both have provisions letting states waive essential health benefits, a key reform from the Affordable Care Act that required all insurers to cover 10 types of procedures and medical services, including pregnancy, maternity, and newborn care. “This means that plans in the individual market could once again decide not to cover maternity care — like 88 percent of plans did before the Affordable Care Act passed," Vox's Sarah Kliff explains.

Old people would also be victims. Under Obamacare, premiums are capped as a share of income, and the caps don't vary by age. Under the BCRA, the caps would vary by age. While a single person earning three times the poverty line ($35,640) pays no more than 9.69 percent of their income on premiums under Obamacare, under the BCRA the caps would vary from 6.4 percent for people under 30 to 16.2 percent for people over 59.

So for a 60-year-old at 300 percent of the poverty line, the maximum premium would go from $3,442 a year to $5,773, per Vox’s Sarah Kliff. And the plan would be less comprehensive, only being required to cover 58 percent of health costs, not 70 percent.

The Medicaid cuts would also hurt disabled students in schools, many of whom receive services in their school districts from the program. Because of the cuts implied by the per capita cap and block grant provisions, AASA, a group representing school superintendents, is warning that school services for disabled children could be cut back or rationed as a result of the federal Medicaid cuts.

“A per-capita cap, even one that is based on different groups of beneficiaries, will disproportionally harm children’s access to care, including services received at school," AASA’s Sasha Pudelski, along with the National Alliance for Medicaid in Education's John Hill and the National Association of School Psychologists' Kelly Vaillancourt Strobach, said in a statement. "Schools are often the hub of the community, and converting Medicaid’s financing structure to per-capita caps threatens to significantly reduce access to comprehensive health care for children with disabilities and those living in poverty."

The Senate bill is mean. If that’s a problem, Trump should promise to veto it.

This is not a compassionate bill. It’s not a bill that tries seriously to reconcile free market principles with a need to protect sick, poor, and vulnerable Americans. There are plans that would do that — ones that cap medical costs as a share of income but preserve a role for private insurance and make patients have skin in the game. They’re not my preferred policy, but they represent serious conservative attempts to generate universal health coverage.

The Better Care Reconciliation Act that the Senate is weighing is not that kind of plan. It’s full of ad hoc, drastic cuts to health care for the poor and disabled, and promises of higher premiums all around. It would put older and pregnant Americans in particularly vulnerable positions. The only real policy goal it accomplishes is funding a big tax cut for top earners. It’s straightforward redistribution from the poor to the rich.

Trump was correct in describing the House bill as “mean.” The Senate bill is just as mean, and cruel, and callous. If Trump was disturbed by the House bill, he should reject the Senate one now. He should promise to veto any bill that reduces the share of Americans with health coverage, and get to work on a new plan that provides “insurance for everybody” and holds Medicaid harmless, just as he promised during the campaign and transition.

It’s not too late.

The GOP plan for Obamacare could kill more people each year than gun homicides
June 26th, 2017, 07:20 PM

If 22 million people lose insurance, we'll see more than 24,000 extra deaths per year.

There’s no question that the fate of Obamacare is a matter of life and death.

The GOP’s senate plan to repeal and replace the Affordable Care Act, the Better Care Reconciliation Act, will result in 22 million fewer people with health insurance by 2026 compared to Obamacare, according to the non-partisan Congressional Budget Office. That’s like taking health coverage away from a country as big as Australia.

If the plan passes through the Senate and becomes law, health researcher and writer Atul Gawande told Vox, “There will be deaths.”

But getting a firm number on exactly how many deaths an ACA repeal would lead to is surprisingly contentious.

We don’t have any direct evidence of Obamacare’s impact on mortality, since it takes a long time for changes in things like health insurance to show up in death statistics, and the law was only enacted in 2009, as I’ve explained in a summary of the science on health insurance and mortality. (Studies looking at whether the ACA improved people’s health status and access to health care have had positive results, which suggests it should increase longevity.)

We do have something else though: very high-quality studies on the impacts of health insurance on mortality, which come to some pretty clear estimates. This research suggests that we would see more than 24,000 extra deaths per year in the US if 20 million people lost their coverage. And 20 million is less than the 22 million Americans the CBO expects will lose insurance by 2026. So the death toll from the GOP’s Obamacare repeal and replacement plan could be even higher.

The best studies on health insurance and mortality suggest 24,000 extra deaths per year if 20 million people lose their health insurance

There are two main types of studies that can tell us something about the effect repealing and replacing the ACA might have on mortality in America: First, there are simple non-randomized observational studies that use large health data sets to compare mortality rates between people who have had health insurance (government or employer-sponsored) and people who have not. Second, there are quasi-experimental studies, a stronger type of observational study design, which compare states that have expanded health insurance with those states that haven’t in a natural experiment.

The simple observational studies have come to pretty mixed conclusions. (You can read more about them here.) So I’ll focus on the higher-quality research on insurance and mortality.

To talk about that research, we have to understand how Medicaid has changed in America in recent years. Traditionally, Medicaid covered only low-income children, parents, and pregnant or disabled people. Over the past 10 years, several states expanded Medicaid coverage to include non-disabled adults who don’t have children — a group that is similar to the population that gained eligibility under Obamacare.

But Medicaid expansion has not been spread evenly throughout the US, and the Supreme Court ruled it was an optional feature of the ACA in 2012. This was clearly a loss for poorer Americans but it was a win for science: It led to a series of natural experiments across the country, in which researchers have compared the mortality rates in places that expanded coverage with the rates in places that didn’t.

  • The researchers behind this 2012 New England Journal of Medicine study took advantage of that variation: They compared what happened to health in three states (New York, Maine, and Arizona) that expanded Medicaid eligibility since 2000 to neighboring states without expansions, covering a period of five years before and five years after each state's expansion. They found mortality declined in places that expanded Medicaid by 20 deaths per 100,000, unlike neighboring states that didn’t expand Medicaid. Extrapolating that to the estimated 20 million who could lose health insurance with an ACA repeal, other researchers have suggested this would translate to 43,956 deaths in the US per year.
  • Massachusetts has also offered a natural experiment for researchers who want to understand the impact of expanding health insurance on mortality rates. The state underwent a health reform in 2006 with the goal of providing insurance to almost all of its residents — and it became the model for the ACA. The best paper on this, published in 2014 in the Annals of Internal Medicine, compared the mortality rates in Massachusetts counties from 2001 to 2005 (before health reform expanded insurance) and 2007 to 2010 (after health reforms) to changes in control counties with similar demographic and economic conditions. Here, they found that the health insurance expansion prevented 320 deaths per year since it began in 2006. If that pattern holds for the ACA, the White House Council of Economic Advisers has estimated that it means 24,000 deaths per year nationwide are averted because of the ACA. (Others, including researcher Harold Pollack, have made the same calculation.)

Unlike the observational studies, which simply compare the uninsured with those who have insurance, these more recent quasi-experiments tell us what happens when uninsured people gain coverage. This is a much more reliable way to find out how many deaths insurance may have averted. And even though they come to different conclusions, they both suggest we’d see a lot of people die if Obamacare is destroyed.

More people would die if the ACA is repealed than are killed by firearm homicides, HIV, and skin cancer each year

So if we trust these “quasi-experiments,” we’re looking at somewhere between 24,000 and nearly 44,000 extra deaths per year if 20 million people lose health insurance with an Obamacare repeal.

That’s still a sizable range, so I reached out to the author on these last two studies, Benjamin Sommers, to ask him about which he thinks is the better model for estimating the impact of repealing the ACA.

Sommers, a health economist and physician at Harvard University who has extensively researched the effects of health insurance, argued for the Massachusetts figure as the “more cautious and reasonable estimate.” The 2006 health care reform in the state became the model for the ACA, so he thinks the experience there — and the population it affected — is a better match for what’s happened nationally than the Medicaid expansion study in New York, Maine, and Arizona.

And 24,000 is still a large number. That’s more than the death tolls from firearm homicides, HIV, and skin cancer in the US each year.

Again, the Congressional Budget Office analysis suggests 22 million people will lose insurance under the GOP Senate’s Better Care Act, which is more than the 20 million these mortality estimates are based on. The CBO estimates the plan will include particularly steep cuts to Medicaid, which covers the most vulnerable Americans, including pregnant women, the disabled, children, and the working poor. It’s their lives that are on the line now.

CBO: 22 million fewer Americans would have insurance under Senate health care bill
June 26th, 2017, 07:20 PM

Under the Senate Republican health care bill, 22 fewer million Americans would have health insurance in 2026, compared with Obamacare, according to new estimates from the Congressional Budget Office.

As soon as next year, 15 million more Americans would be uninsured, the office found in its analysis of the latest Senate GOP plan. Senate leaders are hoping to press forward with a vote on the bill by the end of the week.

By eventually ending the generous federal funding for Obamacare’s Medicaid expansion and overhauling the entire program’s financing, the Senate bill would cut the program’s spending by $772 billion over 10 years, versus what would be expected under current law.

CBO’s projections would represent an abrupt turn from the trends under Obamacare; the US uninsured rate had dropped below 11 percent in late 2016. The office has estimated that there are currently 26 million uninsured Americans; that would increase to 49 million by 2026 under the Senate Republican plan, according to CBO.

The Senate revamped the House GOP, incorporating more of Obamacare’s infrastructure while cutting Medicaid more deeply in later years. The House bill had been estimated to lead to 23 million fewer Americans having health insurance.

Why the CBO’s projection is so important

CBO represents the official analysis of the Senate’s bill, though some Republicans have sought to cast doubt on its accuracy. Several swing votes in the Senate, such as Sen. Susan Collins (R-ME), have said they could not vote for a bill that would lead to tens of millions fewer Americans having health insurance. The new numbers from CBO could make them more skittish about supporting the Senate plan.

Its projections will also help determine what provisions can and cannot be included under the procedural rules Senate Republicans are using to pass a bill with only 50 votes. The bill is supposed to be limited to policies that directly affect federal spending or revenue; CBO’s score helps make those determinations.

More changes could be made to the legislation in the next few days, as Senate leadership presses ahead for a vote by the end of the week. So Monday’s CBO report may not reflect the actual bill that senators will eventually vote on.

The bill would reduce the federal deficit by $321 billion over 10 years, according to CBO. Under the Senate’s rules, the plan only needs to meet the House bill’s savings, which were $119 billion. So Senate Republicans could significantly boost the spending in their bill over the next few days.

Average premiums will eventually decline, but out-of-pocket costs would go up for many people

The Senate’s bill allows insurers to charge older people five times as much as younger people, gives states more flexibility to waive Obamacare’s insurance regulations, and scales back the financial assistance people receive to buy private insurance. Lowering premiums is a priority for many Republicans, and the bill’s supporters argue that these policies would help achieve that.

Average premiums would be about 20 percent lower under the GOP plan, compared to Obamacare, in 2026, CBO found.

But that would be in part because the GOP’s financial assistance is pegged to plans with higher out-of-pocket costs. Most Americans who buy insurance on the individual market would actually end up paying more for health care, even if their premiums went down.

“Because nongroup insurance would pay for a smaller average share of benefits under this legislation, most people purchasing it would have higher out-of-pocket spending on health care than under current law,” CBO’s analysts wrote.

The loosening of state waivers created by Obamacare would also increase health care costs for many Americans, CBO found. The Senate bill allows states to roll back more of Obamacare’s insurance regulations and makes it easier for states to get the waivers.

About half the US population lives in states that would seek waivers from the Obamacare requirement that health plans cover certain essential health benefits, CBO estimated. If states narrowed what services plans are required to cover, people could end up paying more for those services and insurers could again impose annual or lifetimes limits on how much they would pay for those services.

“People who used services or benefits no longer included in the EHBs would experience substantial increases in supplemental premiums or out-of-pocket spending on health care, or would choose to forgo the services,” CBO said, adding of lifetime and annual limits: “some enrollees could see large increases in out-of-pocket spending because annual or lifetime limits would be allowed.”

15 million fewer people would be enrolled in Medicaid, including people currently eligible

The Senate bill eventually ends Obamacare’s generous federal funding for Medicaid expansion, which covered millions of poor Americans, in 2024. It also overhauls the entire program’s financing, placing a federal spending cap on the program for the first time. CBO estimates that, under the Republican plan, Medicaid spending would be cut by $772 billion by 2026, versus current law.

As a result, about 15 million fewer people would be enrolled in Medicaid in 2026 — including about 10 million people currently eligible for the program. The other 5 million are people who would have enrolled had Obamacare remained the law of their land and if their state eventually expanded Medicaid.

 CBO

Under the spending caps, states would make up for the loss in federal funding by adding their own dollars, cutting spending or restricting eligibility — CBO projects that states would adopt a mix of those policies.

If states chose to leave their Medicaid program unchanged and instead found other ways to offset the loss of federal funds, enrollees would notice little or no change in their Medicaid coverage.

...

If states reduced payment rates, fewer providers might be willing to accept Medicaid patients, especially given that, in many cases, Medicaid’s rates are already significantly below those of Medicare or private insurance for some of the same services.

...

If states reduced covered services, some enrollees might decide either to pay out of pocket or to forgo those services entirely. And if states narrowed their categories of eligibility or used administrative procedures that made it more difficult to enroll, some enrollees would lose access to Medicaid coverage, although some would become eligible for subsidies for nongroup coverage through the marketplaces or could choose to enroll in employment-based insurance, if it was available.

Though it did not provide specific estimates, CBO projected that Medicaid enrollment would continue to fall after 2026 under the Senate bill’s spending caps.

“I hate being a refugee”: a Somali mother on the newly reinstated travel ban
June 26th, 2017, 07:20 PM

Istarlin Abdi Halane was thrilled when she found out last year that she’d been chosen to resettle in the United States.

“Maybe after all, my dream is really valid and it’s going to come true,” she thought.

The dream had been a long time coming. Abdi Halane, 28, fled war in her native Somalia as a child. She’d spent most of her life in Kakuma, a refugee camp in Kenya: marrying at 15, a mother of two by 20, divorced by 25. All that time, waiting to find out where she’d be able to build her life.

Finally she got an answer.

“I was so happy when I got the letter,” she said. “I had many friends from America. I saw they’re really nice people. If I’m going to America, then it’s the best thing.”

But this week, her future looks much different. She's just found out that Donald Trump's immigration order will finally go into effect after months of legal challenges. As a Somali citizen and a refugee, the order affects her doubly — she and her daughters will be barred from entering the country for at least 120 days.

"I hate being a refugee," she said. "Every time you see a ray of hope it shatters in front of your eyes."

The immigration order is the realization of her worst fears about Donald Trump’s presidency. During the campaign, she was troubled by what the Republican candidate had to say about immigrants — refugees and Muslims in particular. He kicked off his campaign declaring Mexican immigrants “rapists” and “criminals”; he later called for "a total and complete shutdown of Muslims entering the United States.”

Abdi Halane thought, “If he can think like this now in an election, what will happen if he becomes a president?”

She soon found out when President Trump issued his “travel ban” during his first weeks in office.

President Trump announces executive actions calling for a “great rebuilding” of the U.S. military and a more stringent vetting process for refugees in a ceremony at the Pentagon on January 27. Mandel Ngan/AFP/Getty Images

“Maybe I’m the unluckiest person in this world,” she thought on the day she saw the news.

She didn’t sleep at all that night.

The ban was challenged in court successfully; and for months the order was not in effect. Still, Abdi Halane’s case remained in limbo as she waited to renew her medical certification. All she could do was check her status online.

And now she knows she’ll have to wait several more months before she has any hope of coming to America.

“The only dream that I had, Trump shuttered it,” she said.

America might be a different place than she thought.

Here, in her own words, she describes the pain of realizing she is a refugee; the joy she felt at learning she was chosen to come to the United States; and the uncertainty she faces now that Trump is president.

The images are a typical morning in Abdi Halane's household, waking up at sunrise, making breakfast, and walking her daughters to school.

When she first realized she was a refugee

I was 13 when I realized I was a refugee. I was going to a boarding school that was a 25-minute walk from the refugee camp. Other kids would say, “You’re just a refugee; just go back where you came from. This is not your land. This is our land.”

That’s when it hit me: “Oh, so I’m a refugee.”

I would sit down and cry and cry. My English teacher was my favorite teacher. She would come and talk to me.

“You know what? Being a refugee is okay. It’s just a status — it can change any time,” she told me. “Maybe you will go back to your country; maybe you will go to another country. Your status will change.”

After that, I became bright, and whenever the other kids would tease me, I’d say, “It’s just a status, so don’t worry — I will get my education and it will change.”

A decade and a half later, it looked like her status was finally about to change

It had been years since my interviews with the United Nations High Commissioner on Refugees. I’d stopped checking my status -- I didn’t want to keep on coming back every evening heartbroken. But one day a friend said to me, “There are a lot of submission letters from the US, and I’ve seen your name. Everyone else picked up theirs a long time ago. What happened? It’s like you don’t want to leave the camp.”

I went home in the evening and I showed my daughters the letter.

My older daughter, Naima, said, “We’ll be Americans when we go there. We’re going to have our documents there. I’ll be Naima. I’ll be a Somali American. You know what, Mum? I will no longer be a refugee.”

Abdi Halane watched the 2016 election closely — and assumed Hillary Clinton would win

I was following the election on the internet.

I was 100 percent sure Clinton will win. I was really happy because I really love women leaders. It motivates and gives you courage — like if she made it, you can make it too.

I never liked the way Mr. Trump was talking.

He said he will always put America first, and one of the first things that he will do is he will deport any illegal immigrants that are in his country and no immigrants will be coming to America. That’s what hit me so hard — that and the wall that he said he’s going to build in Mexico.

I said, “If he can think like this now in an election, what will happen if he becomes a president?”

When she found out Trump had won, she worried that she wouldn’t be able to resettle in America after all

The day they announced the results of the election, I was at a conference on girls and education in a nearby town called Lokichogio, on the border between Kenya and Sudan.

I was in the conference hall of the hotel where we were staying, but my mind was on the counting of the votes that was going on halfway around the world. I kept leaving the conference hall to check the hotel television. Each time I saw Trump ahead of Hillary, I got sick to my stomach.

But I didn’t believe he would win until he came out and said, “I won,” and Clinton accepted that. That’s when it hit me. I went to my room and cried so hard.

I was crying because this guy, he never liked refugees. Because I knew once he is the president, I would never go to the United States. I thought, “The only dream that I had, Trump shattered it.” The moment he was chosen, that was the end of me. I was like, “I don’t think I’ll ever go there.”

Then I was crying because my children didn’t know about this election and these political things. They were excited that anytime soon, we would be resettled in America. So what am I going to tell them?

The next day I went home, and I kept quiet at first. I was like, “Let me first be okay; then I can talk to them.”

I said, “Naima and Malyum, do you know what? The new president that the American people have chosen, he is a guy who doesn’t like refugees. I don’t know how our case will be processed. I don’t know if we’re going or not.”

How Trump’s win changed her view of America

I wondered, “What happened to the American people?” Because most of them that I meet, they’re nice people, they’re so friendly. And it’s America that makes the largest donations to the UNHCR. They’re the main people who provide food, everything for the refugees. I wondered how they could choose such a person.

So I asked an American friend of mine: “What is going on with your people?”

She said, “It’s a question many of us have been asking,” and she tried to explain to me: “People got tired of the Democrats. They wanted a change — it’s not Trump they voted for; they voted because of the parties.”

That made sense to me.

When Trump announced his refugee ban in late January, her fears were realized

I found out about the ban from reading the online news on my phone. At the same time, my friends from America were texting and calling. They knew I was almost there; they were waiting for me. They kept on calling: “Istarlin, Istarlin, I’m sorry.”

I thought, “Maybe I’m the unluckiest person in this world. Every time my things work out, something will happen.”

I just felt bad the whole night. I couldn’t sleep.

The next day, I had more messages from my friends in America. They said, “Istarlin, don’t worry! We’re going to fight this ban. We as American people, we own the country. It’s not his country; it’s our country. We will fight this ban, and nobody is on his side.”

I was like, “It’s okay. If I’m meant one day to come to America, then I will come. If it’s not, it’s not.”

Her daughters ask when things are going to change — and she doesn’t have an answer

If it were just me, I would try to forget. But the kids keep on reminding me, “Mum, when are things going to change?”

Sometimes you don’t have an answer. You pretend you never heard that question; you try to dodge the subject and talk about something else. But the girls are too smart for that. They keep on asking.

“I just asked you a question, what’s up with our case, is there anything new, are we really going?”

The elder one says sometimes, “You know what, Mum, I think I should stop thinking about this.”

Then I tell her, “Yes, that’s for the better.”

But the smaller one doesn’t understand that. She keeps on asking me, “Mum, when are we going, are we ever going? Or maybe we’re going to stay in Kakuma forever. I don’t like Kakuma. Kakuma is not a nice place to be.”

I tell her, “In life, you have to be patient.”

She says, “Okay, Mum, I’m a big girl. I’ll be patient.”

I say, “Okay, that’s good for me.”

Abdi Halane looks out over Kakuma camp from Kalemchuch Hill. Asked what she sees when she thinks of a life in the United States, she said, “I see myself and the girls happy. Life won’t be easy, but as long as we have each other it will be perfect. I will drop them to school, I will work and pay our bills. I want to study as well. Life won’t be luxurious, but it will fit our simple way.”

Editor: Eleanor Barkhorn
Photographer: Kainaz Amaria
Copy editor: Tanya Pai
Project manager: Susannah Locke


First Person is Vox's home for compelling, provocative narrative essays. Do you have a story to share? Read our submission guidelines, and pitch us at firstperson@vox.com.

SCOTUS ruled that churches qualify for state money. Churches, beware.
June 26th, 2017, 07:20 PM

For churches, state money can be a poison pill.

The Supreme Court has just ruled that it is unconstitutional for the state of Missouri to deny funds to a Lutheran church that wanted to make use of a state program with a secular purpose: encouraging the use of recycled material. The church had applied for a grant to have the costs for a new school playground partially reimbursed, but was denied because the state constitution forbade making payments to churches.

The Court came to the right conclusion, both constitutionally and ethically. But it’s an entirely different question whether churches should be participating in state-run programs like that one — when they consider their own self-interest.

Secularists worry that when federal or state money goes to churches, to support either charities or efforts like the one at stake in Trinity Lutheran Church of Columbia v. Comer, the state is in effect promoting religion. But there’s growing evidence that the influence goes the other way: State support causes churches to become more secular, and generally to weaken.

In short, believers should be wary of the freedom the Court has just affirmed.

Nonetheless, we should not lose sight of the discriminatory nature of Missouri’s overturned policy. That discriminatory aspect becomes all the more clear when you look at its history. Missouri is one of 38 states with a so-called “Blaine Amendment,” which prohibits the state from giving any aid to parochial schools. Missouri’s amendment originated in the state constitution of 1875, which was then replaced in 1945, with the Blaine Amendment kept.

James G. Blaine was a Republican Congress member from Maine who led a failed effort to amend the US Constitution to forbid public money from going to religious schools. Despite his failure at the federal level, the movement he led greatly influenced the states.

The late-19th-century movement to keep public money out of parochial schools was sometimes driven by religious animus

The origins of that 1875 constitution should be embarrassing for Blaine Amendment supporters. At the time, Missouri was governed by a political coalition that, had Missouri been part of the Confederacy and subject to Reconstruction, we would today call a “Redeemer” government: It was made up of reactionary Democrats determined to roll back the advances made on behalf of African Americans since the Civil War. Thus, the 1875 constitution removed key features of the 1865 constitution, such as its prohibition of certain forms of racial discrimination by the government. The 1875 constitution could well and truly be called a Jim Crow constitution.

The Ku Klux Klan and its political fellow travelers of course directed the lion’s share of their hatred toward African Americans, but they reserved a portion of their fury for those they would tar papists (Roman Catholics) and groups often seen as crypto-papist, like Lutherans or Orthodox Christians. (In fairness, Lutherans also participated in bigotry against Roman Catholics.) No surprise, then, that Democratic governors from 1873 onward also made efforts to restrict certain kinds of education, by starving some (especially black) public schools of money, and, of course, by discriminating against Catholic and Lutheran schools.

Blaine himself was raised in an interfaith household, with a Catholic mother and a Presbyterian father. Whatever his personal sympathies, he was a presidential hopeful and wanted to solidify the Protestant vote for himself. After President Ulysses S. Grant proposed an amendment banning any support for parochial schools, Blaine took up the cause. The amendment failed at the federal level but was popular with the states.

While Reconstruction-era Republicans like Grant and Blaine also favored robust public education, Southern Democrats like those in Missouri saw an opportunity to persecute those drunken immigrant Catholics and Lutherans and restrict the growth of public expenditures. Political persecution of beer-swilling Germans and Irish by political Protestantism was nothing new at the time, and keeping their schools unfunded was key to the longstanding goal of converting Lutherans and Catholics to more truly American religions.

As late as the 1906 US Census of Religious Bodies, about 85 percent of Lutheran churches were bilingual or exclusively used a foreign language, and a series of wars with Germany did not help public perception of these ethnically foreign churches. Meanwhile, Catholicism remained a political question at least as late as JFK’s election.

It’s important to stress that a prohibition on parochial school support did not imply that public schools were secular — Grant famously condemned the “atheistic” tendencies of private schools as one of the justifications for free public schools. These would cure kids of their godless atheism by promoting “nonsectarian,” that is, approximately American Protestant, beliefs. No surprise then that the largest private school networks in the country were the Catholic, Lutheran, and Jewish school systems, as all three groups found preachy Yankee Congregationalists, pietistic Methodist teetotalers, and brimstone-bearing Baptists kind of annoying.

So the Blaine Amendment in Missouri originated in political, nativist Protestantism reacting against Catholic and Lutheran school systems, coinciding with the ascent of more aggressively white supremacist political factions.

The Supreme Court has affirmed that it’s not okay to exclude churches from generalized subsidy programs they otherwise qualify for

That is not the whole story, of course. In the intervening decades, Blaine Amendments in Missouri and other states have seen various modifications, allowing some public funds to ultimately flow toward religious education, especially for special needs students and for religious universities. And, thankfully, modern Americans don’t think of state non-support of parochial schools as a tool for keeping Catholics and Lutherans in their proper place.

But it is a bit disingenuous that anybody thinks state recycling subsidies would promote the Christian religion. Perhaps the Book of Hezekiah contains guidance on recycling? It’s also a bit odd that anybody thinks it’s okay to offer a generalized subsidy program to other schools, but then deny it just because a group is religious. The federal government routinely engages in partnerships with religious charities, as do non-Blaine states. The majority of refugees are resettled via religious charities, for example; oddly enough, the secular left rarely urges that we shut down those groups.

It is profoundly prejudiced, and a bit of a policy-effectiveness own goal, for a state to refuse to support otherwise socially desirable charitable or educational activities solely because they are carried out by religious organizations. Nor is it a good look on the government to say, in essence, “We won’t give you the money now, but renounce Christianity and proclaim yourself secular, and then we will.” Very few people think students at religious universities should be denied access to Pell Grants (vouchers!) or subsidized student loans, or academic research grants, even when those universities explicitly promote their faith and use faith-based standards for admission and enrollment.

Missouri’s new Republican governor, Eric Greitens, recognized the unfairness in how Missouri was treating religious organizations, calling that policy “prejudiced.” The Supreme Court has now affirmed that judgment, with seven justices making a simple but powerful point: The law should not discriminate between theists and nontheists, or between denominations, when providing benefits, programs, or services, period. If you can’t stomach a church (or a mosque) benefiting from a program, don’t have the program. This result presumably pushes the Blaine Amendment in Missouri’s Constitution one step closer to being a dead letter.

Churches should celebrate the Court’s decision, yet think hard about how they’ll act on it

But there’s a catch. Religious people and groups do deserve and are one step closer to receiving equal access to public programs, but if they are wise, they should avoid actually availing themselves of these programs in most cases. The experience of centuries has shown that far from sacralizing the state, public support of religious bodies secularizes the church.

An empty church UniversalImagesGroup / Getty
Research suggests that public support of churches leads to lower levels of church attendance.

There is abundant academic study and demonstration of the state-secularization model. Where there are established state churches, religious attendance is lower. Even in recent years, “deregulation” of religion has boosted religious participation, though not enough to offset a less religious cultural milieu. In colonial America, with its established, state-sponsored churches, just 18 percent of Americans were members of any church, and membership rose consistently until the 1970s; it remains well above 19th-century levels today.

Study of the 1996 welfare reform finds that government spending crowds out church giving by 20 to 38 percent. A study of several Western countries found that expansion of the welfare state largely explains the increase in secularization in recent years. Another study found that in European countries, compulsory schooling reduced religious expression even in countries with religious curriculum in public schools, like the United Kingdom.

But there’s a debate about what exactly is happening here. Does all government provision of benefits reduce religiosity? Or can some church-state partnership in public service provision benefit churches? That’s the classic worry of many secularists: that state support of religion will create religiosity, which might threaten the vital separation of conscience and state on which all peaceful pluralism depends.

However, a working paper released in February suggests that yes, indeed, government support secularizes religious practice, even very recently here in the United States. And the context is interesting, as it’s a study of state support of parochial schools via vouchers, an issue similar in its political meaning, if not in its practical details, to the Trinity case.

The authors of the study found that although an infusion of state money helped to prevent the closure of churches, “We fail to find evidence that vouchers promote religious behavior: voucher expansion causes significant declines in church donations and church spending on non-educational religious purposes” — that is, spending on missions, pastors, church social services, church maintenance, and so on. The effect of this crowding out is genuinely enormous: $230 million in voucher spending at Catholic schools in Milwaukee resulted in $60 million less in church donations, the authors found.

For secularists, voucher programs that help to prop up churches are very nearly the worst kind of church-state intimacy. For many advocates of religious education, meanwhile, state vouchers are seen as a solution to a whole host of problems — and, yes, as a way to promote religiosity. It turns out both sides may be wrong.

Strong government support for religion is a poison pill that offends the secular and defiles the sacred. It is true that denying a church the right to get the state to pay for its playground is mere prejudice written in law, which should be undone, if for no other reason than the appalling historical provenance of these laws. But it is also true that when a church becomes a client of the state, that church has bought itself a potter’s field.

The exact mechanism remains murky, but the broader moral of this story is very clear. For religious people in America, the optimal environment is a maximum of religious liberty — and minimum of state discrimination along religious lines — alongside voluntary avoidance of state support. From hospitals to schools to social welfare, when the state steps in, true religion is usually pushed out.

The secularization of Northern Europe offers a cautionary tale

We can see today the end result of public support for religion in countries like Norway. In that Scandinavian paradise of secular social democracy, between 57 percent and 82 percent of the population, depending on your source, is formally affiliated with a Christian denomination (including 76 percent with the Church of Norway, the state church), but only about 3 percent attend church. In the United States, only about 50 percent of the population is formally affiliated with a Christian denomination, substantially lower than in the Nordic countries, yet somewhere between 15 percent and 40 percent are weekly attendees at church, indicating far greater religiosity.

I have friends who have been parishioners at Trinity Lutheran, and it is preposterous to think that if Missouri helps pay for a playground, that will be the end of true faith there. A playground really is just a playground. But this is how it begins: first with a playground or two, then grants for instructional buildings, then church maintenance, then vouchers for tuition, then direct grants — and pretty soon you’re a public school. And, oh, by the way, the state of Missouri isn’t okay with your pastor preaching this or that teaching of the church anymore. Oh, you want to preach that anyway? Nice school you got there. Shame if anything should happen to it.

So if your end goal for American religion is Scandinavian secularism then, sure, go ahead, throw money at the churches. The road to the death of American religion may well be paved with taxpayer dollars.

Lyman Stone is an economist who blogs at In a State of Migration. He is an enthusiastic and confessing member of the Lutheran ChurchMissouri Synod, a theologically conservative Lutheran denomination; he was raised as, and in his beverage choices remains, a pietistic Methodist teetotaler. Lyman works as an agricultural economist at USDA. His views are not endorsed by, supported by, or in any way reflective of the US government.


The Big Idea is Vox’s home for smart discussion of the most important issues and ideas in politics, science, and culture — typically by outside contributors. If you have an idea for a piece, pitch us at thebigidea@vox.com.

How Harry Potter changed the world
June 26th, 2017, 07:20 PM

Twenty years ago, on June 26, 1997, a small children’s press in the UK took a chance on a work of children’s fiction by a debut author — an unknown single mom who’d first gotten the idea for her story while stuck on a train seven years earlier.

That author was J.K. Rowling. And her book, Harry Potter and the Philosopher’s Stone — published in the US a year later as Harry Potter and the Sorcerer’s Stone — would go on to change the world.

Harry Potter became such an all-encompassing phenomenon that from this vantage point, it’s hard to see the full scope what it accomplished: It feels as though publishing and fandom and children’s literature and all of pop culture have always been the way we know them today. But Harry Potter had a measurable effect on everything it touched. It made YA book-to-movie franchises into one of the biggest forces in pop culture. It changed the business model for publishing books for kids. And it introduced an entire generation to the idea that it’s possible to interact with the pop culture you love — to write about it and with it, to make music and art about it, and to build a business around it.

Here’s a look back at the way Harry Potter changed and influenced online fandom, millennial culture, and the publishing industry.

Harry Potter’s US publication made it a bonafide phenomenon

Harry Potter did fine when it first emerged in the UK 20 years ago, winning a Smarties Award and garnering respectable sales for its publisher, Bloomsbury. But it only started to approach phenomenon levels when Scholastic bought the US publication rights for an astonishing $105,000, about 10 times more than the average foreign rights sale at the time.

Arthur Levine, the Scholastic editor who acquired the books, had an excellent eye for British books that would work in the US, having already acquired the US rights to Redwall and His Dark Materials. But even he didn’t know that Harry Potter would grow as big as it did. He just knew that he loved it and wanted to publish it. Scholastic President Barbara Marcus Barbara Marcus “kept saying ‘do you love it?’ and Arthur said yes, so we went for it,” a Scholastic spokesperson recalled in 2002. “I would have been willing to go further than that if I had to," Levine said in 2007.

The $105,000 sale granted Harry Potter two things: a built-in publicity hook, and a big budget.

The hook came from the press: Newspapers featured articles about the little English book that had garnered such a huge sale. Reviewers wanted to know what kind of book would justify that kind of money. It was a curiosity, and as such, it was a story.

The budget came from Scholastic itself. Whenever a publisher acquires a book, it creates a budget for that book. That budget is structured so that elevating the numbers in one category means elevating the numbers in the next category: If you’re going to invest $105,000 just in acquiring a book, you’re also going to pour extra money into marketing, publicity, and production, so that you have a reasonable chance of making that money back.

So Scholastic invested in a lovely hardcover design for Harry Potter and the Sorcerer’s Stone, with a soon-to-be iconic cover, even though conventional wisdom of the time held that children’s books only made money in paperback. It arranged for Harry Potter to be displayed on the front tables at bookstores, and for ads to appear in the right newspapers and magazines. In short, it gave the book many more resources than are typically afforded to the average debut novel from an unknown author, and that decision paid off.

But none of Scholastic’s efforts would have mattered in the end if the people who picked up the book hadn’t loved it. That’s what pulled Harry Potter out of flash-in-the-pan territory and elevated it into a phenomenon that defined childhood for an entire generation.

Why adults got so obsessed with the Harry Potter books

A 2012 study found that 55 percent of YA novels are bought by adults. In large part, that boom is courtesy of Harry Potter, which became a surprise crossover hit adored by both children and adults, and which made it acceptable for adults to read books that are ostensibly for children.

For some critics, that’s a worrisome development, suggesting that adults are too dull and stupid to appreciate books actually written for adults. But there are plenty of reasons for a grown person to enjoy Harry Potter.

The Harry Potter books combine the intricate plotting of a mystery with the sweep and scope of epic fantasy and the intimacy and character development of a classic boarding school narrative. The result is purely pleasurable to read at any age: The puzzlebox mystery plotting keeps the pages turning propulsively forward, the fantastic mythology gives the world scope and magic and joy, and the boarding school structure makes the characters warm and familiar and charming. It also makes their eventual death (for some) and trauma (for all) deeply affecting.

It’s true that Rowling’s prose is best described as workmanlike and competent; if the reason you read is solely to enjoy perfectly balanced and polished sentences, you may be best served elsewhere. But if you are an adult who can imagine reading for more than one reason (the pleasures of story, the joy of immersing yourself in another world), the Harry Potter books become enormously appealing.

Early on, the books were extremely controversial — and in many ways, they still are

Part of what made Harry Potter such a literary phenomenon is that so many kids were reading the books despite an unprecedented number of attempts to get them to stop reading the books.

The Harry Potter series, like many works of fantasy, involves wizardry and witchcraft. The feeling that the books thus promoted the occult proved to be the basis for constant challenges to the series’ presence in school libraries and bookstores by concerned conservative parents. The books first topped the American Library Association’s list of the most banned books of the year in 1999, and remained in the top spot for most of the next decade.

In some regions, pressure to censor the series was so high it led to lawsuits: In 2003, a judge ordered an Arkansas school district that had removed the books from schools due to promotion of “the religion of witchcraft” to return them. Similar formal attempts at removal persisted into the latter half of the decade, and the books continue to rile up conservative religious leaders who warn of its “demonic” influence.

But witchcraft wasn’t the only evil the books were accused of peddling. In 2007, after the series’ end, J.K. Rowling retroactively outed the powerful wizard Dumbledore as gay. The news prompted Christian scholars to declare the move “nonsense,” while queer fans were in turn angry that Rowling had done so little to make the queer subtext of Dumbledore’s character overt during the time he was actually being written (and alive). In recent years, Rowling has provoked controversy for her series’ lack of diversity, for denying queer sexuality of characters, and many, many more kerfuffles.

All of this controversy speaks not only to concerns that Rowling’s work would negatively influence children, but to the reality that many of those children grew up to be arguably even more progressive than the books they grew up reading — which is, in a way, a confirmation of conservatives’ worst fears about the series.

Harry Potter’s popularity completely changed the publishing industry — and the effect spilled over to Hollywood

Here are just two of the ways Harry Potter changed publishing, and how those changes affected the rest of pop culture:

1) The books made it possible to publish long works aimed at children. Prior to Harry Potter, the accepted wisdom was that kids didn’t have the attention span to read long books. And anyway, the thinking went, kids weren’t buying their own books. Their parents were paying for everything, and they would never be willing to pay an extra dollar or two for a longer book, with its extra printing and binding.

But after Harry Potter became an unstoppable cultural force, and it was clear that fans would keep buying the books no matter what, it started to expand. The last four volumes of the series are all doorstoppers that clock in at well over 700 pages each.

Publishers and children’s writers took notice. Booklist found that middle-grade novels expanded 115.5 percent between 2006 and 2016, the decade in which the Potter novels were at their longest. (They rose only 37.37 percent between 1996 and 2006.)

2) Harry Potter made children’s literature an unstoppable force. Before Harry Potter, children’s literature was often considered an afterthought. Sales were falling. Children, analysts would say wistfully, just weren’t reading anymore.

After Harry Potter, children’s literature became a category full of mega-sellers. In 2004, in the midst of the Harry Potter phenomenon, sales of non-Potter kid lit were increasing by 2 percent a year. Since then, the children’s market as a whole has seen its sales increase by a total of 52 percent (4 percent a year). For comparison, the overall book market has gone up a mere 33 percent since 2004.

The Harry Potter generation likes to read, for sure — millennials read more than any other generation — and it also created a cultural landscape in which books for children are major cultural forces, and a go-to well of ideas for Hollywood. Movie studios scour the children’s bestseller lists for properties they can turn into the next Harry Potter: hence Twilight and The Hunger Games and Divergent and all the rest. Before Harry Potter, the YA book-to-movie franchise was not a cliché. It is now, and that’s because the boy wizard and his friends transformed an entire industry.

Harry Potter fandom also paved the way for the mainstreaming of fandom and geek culture

Harry Potter has a tremendously outsized cultural reach: One 2011 survey suggested that a third of all American adults ages 18 to 34 at the time had read at least one of the books. But what really makes Harry Potter stand out is the way people loved (and continue to love) Harry Potter.

First and foremost, the series helped make it cool to be a geek. People generally didn’t read the Harry Potter books in isolation; they wanted to talk about it with their friends, and then find more friends who loved the books as much as they did. This pattern coincided with the rise of “Web 2.0” — that is, an increasingly interactive and social internet. As more Harry Potter fans became more active online, they made discussion of YA fiction, fantasy, and science fiction seem commonplace.

This was still a pretty bold concept in the early 2000s; geek culture was largely still underground, and fantasy was seen mainly as an immature hobby — for instance, in 2003, critic A.S. Byatt’s excoriation of “Harry Potter and the childish adult” claimed that adults “like to regress” when they read children’s literature. But between Harry Potter, the Lord of the Rings film adaptations, and the emerging visibility of online Harry Potter fandom, it was increasingly difficult to ignore fantasy and science fiction as a driving force of culture, and to write off fans of these genres as niche. By the time Twilight took over from Harry Potter as the reigning young adult phenomenon in 2005, the idea of a modern, mainstream fandom coalescing around a major sci-fi/fantasy series was well-established and generally accepted.

And Harry Potter fans’ creativity is still being felt in and outside of the fandom. In the early 2000s, Harry Potter fan forums, fanfiction and fan art archives, and email discussion groups exploded across the internet. Harry Potter conventions drew thousands of fans, and Harry Potter cosplay became a well-known sight at larger geek and comic cons.

Around the same time, the “Wizard Rock” trend (shorthanded Wrock) gained momentum as Harry Potter fans on YouTube formed a litany of music groups — the first one being Harry and the Potters — devoted to personifying and singing about various characters from the books. It was later joined by another totally unique-to-Harry-Potter fan pursuit: Quidditch. In 2005, students at Vermont’s Middlebury college created the first real-life Quidditch game, which went on to spawn an international real-world college sport.

A number of Harry Potter fans also went on to make significant marks on mainstream culture. As a member of the University of Michigan theater troupe Starkid, a young Darren Criss starred as Harry Potter in the viral YouTube video A Very Potter Musical, and his popularity catapulted him into the role of Blaine on Glee and a career on Broadway.

Two longtime members of Harry Potter fandom, siblings John and Hank Green — now known more widely as the Vlogbrothers — got their start on YouTube during the site’s relative infancy, but it wasn’t until Hank Green’s 2007 song “Accio Deathly Hallows” went viral on the eve of the final Harry Potter book’s release that they became the true YouTube stars and industry success models they are today.

And the list goes on: The author of the bestselling Mortal Instruments series, Cassandra Clare first gained fame online as Cassandra Claire, author of the incredibly popular Harry Potter fanfic The Draco Trilogy. Other Harry Potter fans, like fan convention organizer Melissa Anelli and social activist Andrew Slack launched careers directly out of Harry Potter fandom. In general, the Harry Potter fandom was among the first to see a number of people actively leveraging their success through fandom toward their professional careers. Just as Harry Potter made it easier for fans to own their geeky habits, the Harry Potter fandom made it easier for fans to market those geeky habits as professional assets.

What made all of this possible — the industries transformed, the careers built — are the books themselves, and the expansive, wondrous world they created. The Harry Potter series is a phenomenon not just because it had a good publicity and marketing budget (although that helped) and not just because the curiosity and controversy surrounding it made it appealing to the press (although that helped). The Harry Potter series is a phenomenon because it tells a story that millions of people loved, and it introduced the world to an enormous and magical world that millions of people have dreamed of escaping into.

That’s why we’re still talking about these books 20 years later, and that’s why all of this matters.


Watch: Harry Potter and the translator's nightmare

What you need to know about the Supreme Court’s 3 big Monday decisions
June 26th, 2017, 07:20 PM

The Supreme Court wrapped its session Monday morning, but before the justices’ summer recess, the Court made major announcements on three high-profile cases — two of which the Court will take up in the fall.

Perhaps the biggest case the Court will be taking up is President Donald Trump’s travel ban — a revised version of the “Muslim ban” he advocated for on the campaign trail. The justices will also consider a case on religious liberty and the right to refuse services to same-sex weddings, and it decided a case in favor of a Missouri church’s right to state funding.

Here’s what you need to know about these three consequential Supreme Court cases.

The travel ban

After multiple defeats in the appellate courts, the Trump administration finally earned a victory to the president’s travel ban executive order. Though the Court hasn’t affirmatively ruled in favor of the case, they have lifted previous courts’ stays on the ban, meaning travel restrictions will go into effect this Thursday. Importantly, there are still a lot of unanswered questions about what this means for tourists from six Muslim-majority countries and potentially many more refugees.

But first, it’s important to understand the evolution of this case. On January 27, 2017, President Trump signed an executive order that prevented people from seven countries (Iran, Iraq, Libya, Somalia, Sudan, Syria, and Yemen) from entering the US for 90 days. It also suspended the United States Refugee Admissions Program for 120 days and limited the number of refugees allowed in the US unless they were “persecuted religious minorities.”

In the midst of widespread protests at airports and reports of refugees, immigrants, and green-card holders barred from flights to the US, orders were challenged by some state judges within hours and in two different federal courts the following week. It was determined that the ban would be suspended while judges decide on its constitutionality.

A second order was issued on March 6, 2017, which took Iraq off the 90-day suspension list, kept the USRAP suspension to 120 days, and maintained the 50,000-refugee limit. That new version was then blocked by the Ninth US Circuit Court of Appeals — which upheld a Hawaii judge’s lower court decision — and the Fourth US Circuit Court of Appeals. The Trump administration’s next move was to take the ban to the Supreme Court.

On Monday, the Supreme Court ruled that the Trump administration will be allowed to uphold the ban over the summer before the case enters consideration in the fall.

As Vox’s Dara Lind notes, by the time the Court hears the case against the travel ban when sessions resume in October, “the 90-day ban will likely have been completed — potentially replaced by a longer, indefinite ban on entries from countries that don’t provide enough information to the US.” Dara writes:

It’s a massive victory for the Trump administration, which before Monday couldn’t get a break in court. Even if the Supreme Court ultimately rules that the lower courts were correct to stop the travel ban from going into effect, it’ll be totally moot — the bans will already have happened.

Read Dara Lind’s full explainer on this case.

Same-sex wedding cake

Masterpiece Cakeshop v. Colorado Civil Rights Commission revolves around a gay couple who ordered a custom wedding cake from a Colorado-based bakery in 2012 — before same-sex marriages were legally established in the state. The couple, David Mullins and Charlie Craig, planned to marry in Massachusetts, where same-sex marriage had been legal since 2004, and celebrate in Colorado. Masterpiece Cakeshop owner Jack Phillips refused to make the cake for the couple, arguing that forcing him to make the cake would be infringing upon his right to religious freedom as a Christian.

As Vox’s German Lopez reports, the lower courts upheld the current Colorado public accommodations law, “which prohibits discrimination on the basis of sexual orientation and gender identity in public accommodations, such as bakeries.” Lopez writes:

If the Court rules in favor of Phillips, it would be a huge blow to LGBTQ civil rights laws — and not just in the context of bakeries. It could also open a legal path to anti-LGBTQ discrimination in multiple settings, from the workplace to housing, by letting business owners — even in states where such discrimination is prohibited — cite their religious beliefs to discriminate.

The Court is expected to take the case up in October.

Missouri church

In the case of Trinity Lutheran v. Comer, the Court decided in favor of Trinity Lutheran Church, ruling that the Lutheran preschool in Columbia, Missouri, was unfairly denied state funds to purchase rubber tires to resurface a playground due to its religious affiliation.

In 2012, the Church applied for a grant with the Missouri Department of Natural Resources to help pay for recycled tires for the playground. Trinity Lutheran was denied based on a section of Missouri’s constitution, which reads “no money shall ever be taken from the public treasury, directly or indirectly, in aid of any church, section or denomination of religion.” Trinity subsequently sued the state on the basis of religious discrimination.

After lower courts dismissed the church’s claims, Trinity took its case to the Supreme Court in January 2016 and heard oral arguments in April. The Court overturned the lower courts’ rulings on Monday morning.

As Vox’s religion reporter Tara Burton writes, this decision could have major implications, including “setting a precedent allowing state funds to flow to religious institutions which could be used to legitimize discrimination on religious grounds.” Burton writes:

The Trinity case could potentially be one of the most significant SCOTUS decisions of the year, setting the tone for generations of legislation about the separation between church and state on the state level, and potentially paving the way for more radical education reform, like the use of state vouchers for religious schools.

Wonder Woman is now the biggest live-action film directed by a woman
June 26th, 2017, 07:20 PM

The film’s $652 million worldwide box office haul just broke the record.

Wonder Woman made an estimated $25 million at the US box office this weekend, and in doing so set a new record: The movie is now the biggest live-action movie in Hollywood history directed by a woman.

According to Box Office Mojo, Wonder Woman has made $652 million worldwide and $318 million domestically since its release on June 2. The previous record holder was the Abba-inspired musical Mamma Mia, which was directed by Phyllida Lloyd and made $609 million worldwide ($144 million domestic) in 2008.

In terms of superhero films, Wonder Woman has already made more money domestically than movies like The Amazing Spider-Man (2012), Man of Steel (2013), Captain America: The Winter Soldier (2014), and Doctor Strange (2016). It has yet to beat those movies in worldwide box office figures, but it’s only in the fourth week of its theatrical run and will likely remain in theaters for several more weeks.

It’s also within striking distance of the domestic hauls for last year’s Batman v Superman: Dawn of Justice ($330 million) and Suicide Squad ($325 million). What separates those two movies from Wonder Woman is that Wonder Woman has seen less of a decrease in box office sales since its opening weekend. Batman v Superman and Suicide Squad both saw dramatic drops after their premieres (and in Batman v Superman’s case, that drop was a historic one).

These numbers matter to both fans and Hollywood insiders, because there’s unbelievable pressure on Wonder Woman to do well at the box office. It’s an unfortunate reality that in the past, poorly received female superhero movies like Catwoman and Elektra have been cited as a reason not to create more superhero movies centered on female characters. Though, given Wonder Woman’s success, a sequel at this point is nearly inevitable — it’s simply a matter of giving director Patty Jenkins what she wants.

How the Senate’s revised bill punishes you for not having insurance, explained with a cartoon
June 26th, 2017, 07:20 PM

Senate Republicans released their health bill last week, but there was a gaping hole in the text: There was no provision that incentivized people to stay insured. That’s why some analysts thought this would send the individual market into a death spiral, meaning premiums would skyrocket as healthier people dropped coverage.

But the revised bill, released Monday, tries to fix this with what is called a “waiting period.”

If you don’t have health coverage for more than 63 days, then when you show up to buy health insurance during the enrollment period, you’ll be told you have to wait another six months before you can buy insurance on the exchange.

The hope is that this penalty will incentivize enough healthy people to stay insured.

To understand what’s happening here, let’s delve into how Obamacare deals with this, and how Republicans are trying to change it.

How Obamacare works

Imagine a group of people, ranging from healthy to sick:

Obamacare forces insurance companies to accept all these people, regardless of any preexisting conditions. So this raises costs for everyone — including healthy people.

Here’s how Obamacare deals with that. Keep track of those gauges on the top right of each panel that say how sick the pool is and how much insurance costs:

In short, it incentivizes healthy people to stay in the pool by a) giving subsidies based on income, and b) fining people for not having insurance.

If you force insurance companies to accept everyone, you need something that incentivizes healthy people to stay

The reason Obamacare’s individual mandate is crucial is because without it, the individual market could collapse in what is called a “death spiral.”

Here’s what could happen:

Here’s how Senate Republicans want to address this

But the individual mandate is the least popular part of Obamacare and, outside of low-income people who can’t afford the penalty, it creates no case in which an individual can opt to stay uninsured without paying a penalty.

So Senate Republicans are looking to replace the mandate with something else:

As my colleagues, Sarah Kliff and Dylan Scott, write:

Senate Republicans have settled a six-month waiting period as their replacement policy. This means that those who show up during open enrollment to purchase coverage, but have had a break in coverage longer than 63 days, will have to wait six months from the date of their application for their coverage to kick in. They would not have to pay premiums during that time period.

We don’t know whether this incentive is enough to keep healthy people in the market. But the trade-off here is that, instead of punishing people monetarily for not having insurance, it will punish people who want coverage by withholding it from them for six months — and hope that this possibility incentivizes people to stay covered.

The rise, fall, and partial resurrection of Trump’s travel ban, explained
June 26th, 2017, 07:20 PM

The travel ban is coming back on Thursday — sort of. Here’s what you need to know.

The Trump administration has finally secured a victory on its “travel ban” — which will bar some citizens of six majority-Muslim countries from entering the US for a period of 90 days, and an untold number of refugees from entering the country for 120 days.

The Supreme Court ruled Monday that despite appellate courts in two different federal courts blocking the ban while judges decide whether it’s constitutional, the Trump administration should be allowed to enforce the ban starting on Thursday, June 29 (72 hours after the court’s ruling was issued). The Supreme Court will take up the question of constitutionality this fall.

The Trump administration will begin to bar some citizens of Iran, Libya, Somalia, Sudan, Syria, and Yemen from entering the US for 90 days later this week. And it will be able to stop some refugees from entering for 120 days.

But anyone who already has a valid visa should still be allowed to enter the country. And because of limitations placed on the administration by the Court’s ruling, the administration isn’t supposed to deny visas to anyone who has a “bona fide relationship” with a person or organization inside the United States.

The Supreme Court offered some guidance about who will be allowed to enter under its modified ban. But there are still big questions about how the administration will implement it — especially when it comes to refugees.

The Court will hear the lawsuits against the ban in the fall. But the legal fight has suddenly turned anticlimactic. For the first time since February, the Trump administration’s signature immigration policy is going to shape people’s lives.

The Trump administration’s first court win came not a moment too soon

When Donald Trump was inaugurated, his promise to bar people from countries compromised by terrorism from entering the US was one of his signature policy initiatives. Before the Supreme Court’s ruling on Monday, it was in danger of becoming a punchline — the most embarrassing and high-profile setback in an administration that’s had plenty.

On January 27, President Trump signed an executive order that prevented anyone from Iraq, Iran, Libya, Somalia, Sudan, Syria, or Yemen from entering the US for the next 90 days, while the federal government undertook a review of the visa-granting process to figure out which countries didn’t provide enough information about people seeking to come to the US. Additionally, he barred refugees from coming to the US for 120 days — unless they were “persecuted religious minorities”; barred Syrian refugees indefinitely; and slashed the total number of refugees the US would accept in a year, even after the initial ban had passed.

The order didn’t explicitly single out Muslim immigrants. But to many, the connection was clear enough on its own. After all, before candidate Trump promised to bar immigration based on country, he’d called for a “total and complete shutdown of Muslims entering the United States.”

The order was signed on a Friday night — with key officials in the government not knowing what it said until afterward (and even disagreeing with each other about who, exactly, was banned). By midnight, it had gone into effect. And chaos reigned.

 Mark Ralston/AFP/Getty Images
A pro-Trump supporter stands in front of a protest against the immigration ban at the Los Angeles International Airport on January 30, 2017.

Customs and Border Protection officials weren’t trained on what, exactly, they were supposed to do to implement the ban. Dozens of people were held in airports after arriving in the US, interrogated, and often sent back. Pro bono lawyers and protesters amassed at major airports. And 50,000 permanent residents of the United States were told they would be prevented from leaving and reentering the country — and then, ultimately, told they weren’t covered in the ban.

Then, after a little less than a week, the whole thing was put on hold.

A group of states sued the administration over the ban, which they argued was unconstitutional; on February 3, a federal judge agreed that the administration had to stop enforcing the ban until the court case had been resolved. The Ninth Circuit Court of Appeals also sided against the administration.

The administration, seeing the writing on the wall, decided to go back and try again. Trying to build a case that the ban was needed for national security purposes, it asked several government agencies for feedback (though many of the agencies replied that a country-based ban made no sense). It narrowed the scope of the ban to respond to the courts’ objections. And on March 6, it issued a new version of the executive order to go into effect on March 16.

It never got there. On the eve of the “travel ban 2.0” going into effect, federal judges in Maryland (in a lawsuit filed by a coalition of advocacy groups) and Hawaii (in a lawsuit led by Hawaii and other states) did the same thing the Washington judge had done to the first travel ban: They put it on hold while they considered its constitutionality more fully. Appellate courts in the East Coast Fourth Circuit and the West Coast Ninth Circuit agreed.

By the time the Trump administration appealed the case to the Supreme Court — mere weeks before the highest court took its summer recess — it hadn’t had a single victory in two rounds of litigation.

Furthermore, it was in danger of losing the ability to institute a temporary ban at all. In early June, the Ninth Circuit ruled that the Trump administration would be allowed to start the review of visa procedures that the 90-day ban was supposed to make easier — it just wouldn’t be able to put the 90-day ban itself in place. The administration, therefore, was facing the possibility that by the time the Supreme Court took up the case, it would already have had 90 days to review visa procedures — and would have a much harder time arguing a ban was needed to begin with.

But the Supreme Court gave the administration the win it needed, right when it needed it.

People without a “bona fide relationship” to the US can be banned starting Thursday

The Supreme Court’s ruling, issued Monday on the last day of the term before its summer recess, was unsigned. Six justices — the Court’s four liberal justices (Ruth Bader Ginsburg, Stephen Breyer, Sonia Sotomayor, and Elena Kagan) joined Justice Anthony Kennedy and Chief Justice John Roberts in partially lifting the hold on the ban. Conservative Justices Neil Gorsuch, Clarence Thomas, and Samuel Alito argued that the Trump administration should be allowed to enforce the ban in all cases.

The Court’s ruling is technically a “partial stay” of the lower courts’ injunction. In plain English, the Supreme Court has stopped the hold on the travel ban in certain cases, allowing the administration to ban some of the people it wanted to ban from the US.

Due to the Court’s ruling, the Trump administration will be able to bar citizens of Iran, Libya, Somalia, Sudan, Syria, and Yemen from entering the United States for a period of 90 days, and bar nearly all refugees from entering the US for a period of 120 days — but only if they haven’t already been issued a valid visa, and only if they don’t have a “bona fide relationship with a person or entity in the United States.”

 Andrea Morales/Getty Images
President Donald Trump speaks at a rally on March 15, 2017, in Nashville, Tennessee. During his speech, Trump promised to repeal and replace Obamacare and criticized the decision by a federal judge in Hawaii that halted the latest version of the travel ban.

The question this raises, of course, is what counts as a “bona fide” relationship. And while the Supreme Court sort of answers that question, it leaves some big gaps — especially when it comes to refugees.

As Vox’s Tara Golshan reported Monday, many groups that assist refugees are trying to figure out for themselves what this ruling means.

“With this administration, you can’t take anything off the table because of just how inconsistent the implementation has been,” Justin Cox, staff attorney with the National Immigration Law Center, told Golshan.

The Court’s ruling Monday specifies that people “coming to live with or visit a family member” should be allowed into the US, even if they come from one of the six blacklisted countries (or are a refugee) and even if they didn’t already have a valid visa when the ban goes into effect on June 29. So will people coming to study, teach, or speak at American schools or work for American businesses.

That covers a whole lot of people who come to the US on visas. In fact, the only people likely to be barred from entering the US because they come from one of the six blacklisted countries are tourists who aren’t coming to visit family in the US.

But when it comes to the other ban — the 120-day ban on refugees — the Court’s decision is much muddier, and possibly much, much broader.

Refugees don’t already have jobs before they’re allowed to settle in the US, and many of them don’t already have close family here. Few refugees are likely to fall into one of the specific “bona fide relationships” that the Supreme Court opinion explicitly calls out.

But all refugees do have a relationship with a US-based organization. US-based “refugee resettlement agencies” are responsible for settling refugees in the United States, and every refugee entering the US has already been placed with an agency.

The problem is that the Supreme Court didn’t clarify whether being a client of a refugee resettlement agency counts as a “bona fide relationship” — indeed, the fact that it specified that refugees should only be allowed into the US if they have a “bona fide relationship” implies that they think at least some refugees don’t meet that standard (which would mean a resettlement agency doesn’t count). But it didn’t explicitly say resettlement agencies don’t count, either.

Many of the organizations that have fought the travel ban so far believe that the Supreme Court’s ruling shouldn’t bar any refugee who’s already been placed with a resettlement agency. But that doesn’t mean the Trump administration will agree. If the Trump administration starts denying visas to refugees who’ve already been accepted for resettlement, it will likely face a whole new round of lawsuits — and the legal fight over the travel ban will continue over the summer. But this time, the Trump administration will be coming from a position of strength.

Don’t expect airport chaos. Do expect a lot more lawsuits.

The Supreme Court’s ruling lifted the hold on the executive order effective immediately. But thanks to a memo issued last week by the Trump administration, the government has 72 hours to put the modified ban into effect.

That’s more time than the government got to figure out how to enforce the first version of the travel ban, in January. But it’s less time than it gave itself in March, before the courts stopped the second version of the ban on the eve of its implementation.

For an administration that isn’t known for its smooth management style or its flawless coordination of complicated government initiatives, that might not be enough time to make sure the ban is being implemented exactly as the Supreme Court has now allowed it.

Under the terms of the March executive order, the ban is only supposed to apply to people who haven’t already been issued valid visas to come to the US. Since people can only fly to the US if they have valid visas, this should mean that no one is detained at a US airport under the terms of the ban after Thursday.

 Scott Olson/Getty Images
A supporter waits at O'Hare Airport for Syrian refugee Baraa Haj Khalaf and her family to arrive on a flight from Istanbul, Turkey, on February 7, 2017. Khalaf had spent the past five years in a refugee camp in Turkey. Her trip to the United States, with her husband and young daughter, was suspended after President Donald Trump signed an executive order stopping Syrian refugees from entering the US.

It’s possible that (just like the first time) Customs and Border Protection agents at airports won’t be given any training about how to implement the ban — and it’s possible that when left to their own devices, they might get overly aggressive about enforcing it.

But because of the differences between the original travel ban and this one, it’s likely that enforcement of the travel ban won’t be taking place at airports or anywhere else outraged lawyers and progressives can amass. It’s probably going to happen outside the US, at consulates abroad, where officials will refuse to grant a visa to citizen from affected countries because they don’t think he has a “bona fide” enough relationship to something in the US. And it’s going to happen at refugee camps and other processing facilities, where people in the midst of the two-year process to be allowed to come to the US as a refugee will find that two years extended by another four months (or longer, depending on what new procedures are put into place after the 120 days are up).

Unless the Trump administration is extremely cautious, and only denies visas to people in very limited cases, it’s likely to face court battles over the definition of a “bona fide” relationship. (Indeed, this was part of the reason the conservative justices argued the ban needed to go into effect in full; they thought the Supreme Court ruling was just going to open a flood of new lawsuits.) But now that the Supreme Court itself has ruled, these lawsuits aren’t going to result in broad rulings against the ban as a whole. They’ll just be tinkering around the edges, figuring out whether one person, or one group of people in similar circumstances, has “bona fide” reasons to enter the US.

By the time the Supreme Court actually hears the case, the case may be moot

The Court has agreed to hear the case against the travel ban when it comes back in session in October. By that point, the 90-day ban will likely have been completed, and the 120-day refugee ban may be nearing its end as well.

Indeed, by the time the Court takes up the case, the temporary ban may well have been replaced with an indefinite one.

Now that the Trump administration has been allowed to put its 90-day travel ban into effect, it — in theory — should be able to complete a full review of visa procedures (which was the reason it claimed it needed to institute the ban to begin with). It then should have a list of countries that don’t provide enough information to the US to be able to screen their citizens. Those countries, per the executive order, will then be given notice that they need to start providing more info to the US — and if they don’t shape up, they’ll be put on an indefinite visa blacklist until they do.

It’s totally unclear whether the indefinite blacklist will be narrower, or broader, than the list of six countries. And, importantly, the challenges to the travel ban so far haven’t really touched on whether the indefinite blacklist is unconstitutional. So it’s entirely possible that by the time the Supreme Court hears oral arguments about the constitutionality of Trump’s executive order, the most controversial parts of the executive order will already have come and gone.

The Trump administration has its ban. As policy, it’s not quite as sweeping as it initially wanted; depending on how the refugee question gets settled, the administration might have half a ban or might have not much of a ban at all. But it’s been spared the embarrassment of having tried to rewrite an executive order to pass court muster, only to have it completely dismissed by the courts. Instead, it’s the challengers of the travel ban who are now facing what might be an empty victory: No one’s said the travel ban is certainly constitutional, but it’s going to happen anyway.

The war in Yemen has led to the worst cholera outbreak in the world
June 26th, 2017, 07:20 PM

“In just two months, cholera has spread to almost every [part] of this war-torn country.”

The ongoing civil war in Yemen has unleashed another horror: a massive outbreak of cholera, with more than 200,000 suspected cases and 5,000 more being added per day. More than 1,300 victims have already died, a quarter of them children.

“In just two months, cholera has spread to almost every [part] of this war-torn country,” the United Nations said in statement Saturday. “We are now facing the worst cholera outbreak in the world.”

Yemen’s civil war erupted in 2014 when Iran-backed Houthi rebels ousted the country’s Saudi Arabia–backed central government. It has since evolved into a violent proxy war between the two regional powers that has killed more than 10,000 and pushed close to 3 million Yemenis out of their homes. Saudi Arabia has increased its involvement with US help, increasing ground troops and airstrikes: on Friday, the last day of the Muslim holiday of Ramadan, Saudi Arabia ordered over 50 airstrikes in just 24 hours. This came just days after a Saudi airstrike on a market in northern Yemen killed 25 Yemenis.

This brutal military campaign has destroyed much of the country’s infrastructure, causing the spread of easily preventable diseases like cholera. According to the UN, 14.5 million people — which is more than half the country — has already lost access to clean water and sanitation as a direct result of the war.

The fighting needs to stop for the outbreak to end

Cholera is caused by a bacterial infection of the intestine that leads to severe diarrhea and vomiting. In theory, it’s an easy disease to treat.

“The prompt administration of oral rehydration salts to replace lost fluids nearly always results in a cure,” writes the World Health Organization.

The problem is that in Yemen right now, even clean water is a luxury. Water and sanitation systems have been severely damaged in recent months as a direct result of the fighting, UNICEF spokesperson Najwa Mekki said in an interview.

In January of last year, a water desalination plant in the city of Mokha was destroyed by reported airstrikes from the Saudi-led coalition group. This cut off more than a million people in the nearby city of Taiz from their only source of clean water.

More recently, in April, the sewer system in the capital city of Sana’a stopped working, though it’s not clear if this was the direct result of military strikes. Ten days later, a cholera epidemic hit the city, according to the BBC.

In the absence of working water and sanitation systems, cholera is not just hard to treat — it’s deadly. The disease spreads through water, so once a central water source is contaminated, everyone who relies on it is likely to get the disease. It’s made worse during emergencies such as the Yemeni civil war where people are huddled in overcrowded refugee camps, sharing whatever scarce supply of water there is.

Once they contract the disease, many Yemenis die without the right medical care, some within hours. The health system in Yemen has nearly collapsed, said Mekki. Half of the country’s health care facilities, which include clinics and hospitals, are not functioning. Close to 15 million people have no access to health care.

Yemen’s youngest and most defenseless are suffering the worst. Children under the age of 5 have the highest incidence of cholera, and account for close to half of the fatalities. Hundreds of Yemeni children have already died from the disease, and this number is likely to climb with the 5,000 new cases of cholera being reported daily.

The conflict in Yemen has inflicted a particularly heavy toll on children, Mekki said. Apart from the cholera outbreak, more than 400,000 of the country’s children face malnutrition, and nearly 2 million have been taken out of school, an increasing number of whom are being recruited as child soldiers, reported Amnesty International.

Yemeni children have been living a nightmare for more than two years. Amazingly, and horrifyingly, it’s still getting worse.

Getting chosen to come to America was her dream come true. Then Trump won.
June 26th, 2017, 07:20 PM

"I knew once he is the president, I would never go to the United States."

Istarlin Abdi Halane was thrilled when she found out last year that she’d been chosen to resettle in the United States.

“Maybe after all, my dream is really valid and it’s going to come true,” she thought.

The dream had been a long time coming. Abdi Halane, 28, fled war in her native Somalia as a child. She’d spent most of her life in Kakuma, a refugee camp in Kenya: marrying at 15, a mother of two by 20, divorced by 25. All that time, waiting to find out where she’d be able to build her life.

Finally she got an answer.

“I was so happy when I got the letter,” she said. “I had many friends from America. I saw they’re really nice people. If I’m going to America, then it’s the best thing.”

But this week, her future looks much different. She's just found out that Donald Trump's immigration order will finally go into effect after months of legal challenges. As a Somali citizen and a refugee, the order affects her doubly — she and her daughters will be barred from entering the country for at least 120 days.

"I hate being a refugee," she said. "Every time you see a ray of hope it shatters in front of your eyes."

The immigration order is the realization of her worst fears about Donald Trump’s presidency. During the campaign, she was troubled by what the Republican candidate had to say about immigrants — refugees and Muslims in particular. He kicked off his campaign declaring Mexican immigrants “rapists” and “criminals”; he later called for "a total and complete shutdown of Muslims entering the United States.”

Abdi Halane thought, “If he can think like this now in an election, what will happen if he becomes a president?”

She soon found out when President Trump issued his “travel ban” during his first weeks in office.

President Trump announces executive actions calling for a “great rebuilding” of the U.S. military and a more stringent vetting process for refugees in a ceremony at the Pentagon on January 27. Mandel Ngan/AFP/Getty Images

“Maybe I’m the unluckiest person in this world,” she thought on the day she saw the news.

She didn’t sleep at all that night.

The ban was challenged in court successfully; and for months the order was not in effect. Still, Abdi Halane’s case remained in limbo as she waited to renew her medical certification. All she could do was check her status online.

And now she knows she’ll have to wait several more months before she has any hope of coming to America.

“The only dream that I had, Trump shuttered it,” she said.

America might be a different place than she thought.

Here, in her own words, she describes the pain of realizing she is a refugee; the joy she felt at learning she was chosen to come to the United States; and the uncertainty she faces now that Trump is president.

The images are a typical morning in Abdi Halane's household, waking up at sunrise, making breakfast, and walking her daughters to school.

When she first realized she was a refugee

I was 13 when I realized I was a refugee. I was going to a boarding school that was a 25-minute walk from the refugee camp. Other kids would say, “You’re just a refugee; just go back where you came from. This is not your land. This is our land.”

That’s when it hit me: “Oh, so I’m a refugee.”

I would sit down and cry and cry. My English teacher was my favorite teacher. She would come and talk to me.

“You know what? Being a refugee is okay. It’s just a status — it can change any time,” she told me. “Maybe you will go back to your country; maybe you will go to another country. Your status will change.”

After that, I became bright, and whenever the other kids would tease me, I’d say, “It’s just a status, so don’t worry — I will get my education and it will change.”

A decade and a half later, it looked like her status was finally about to change

It had been years since my interviews with the United Nations High Commissioner on Refugees. I’d stopped checking my status -- I didn’t want to keep on coming back every evening heartbroken. But one day a friend said to me, “There are a lot of submission letters from the US, and I’ve seen your name. Everyone else picked up theirs a long time ago. What happened? It’s like you don’t want to leave the camp.”

I went home in the evening and I showed my daughters the letter.

My older daughter, Naima, said, “We’ll be Americans when we go there. We’re going to have our documents there. I’ll be Naima. I’ll be a Somali American. You know what, Mum? I will no longer be a refugee.”

Abdi Halane watched the 2016 election closely — and assumed Hillary Clinton would win

I was following the election on the internet.

I was 100 percent sure Clinton will win. I was really happy because I really love women leaders. It motivates and gives you courage — like if she made it, you can make it too.

I never liked the way Mr. Trump was talking.

He said he will always put America first, and one of the first things that he will do is he will deport any illegal immigrants that are in his country and no immigrants will be coming to America. That’s what hit me so hard — that and the wall that he said he’s going to build in Mexico.

I said, “If he can think like this now in an election, what will happen if he becomes a president?”

When she found out Trump had won, she worried that she wouldn’t be able to resettle in America after all

The day they announced the results of the election, I was at a conference on girls and education in a nearby town called Lokichogio, on the border between Kenya and Sudan.

I was in the conference hall of the hotel where we were staying, but my mind was on the counting of the votes that was going on halfway around the world. I kept leaving the conference hall to check the hotel television. Each time I saw Trump ahead of Hillary, I got sick to my stomach.

But I didn’t believe he would win until he came out and said, “I won,” and Clinton accepted that. That’s when it hit me. I went to my room and cried so hard.

I was crying because this guy, he never liked refugees. Because I knew once he is the president, I would never go to the United States. I thought, “The only dream that I had, Trump shattered it.” The moment he was chosen, that was the end of me. I was like, “I don’t think I’ll ever go there.”

Then I was crying because my children didn’t know about this election and these political things. They were excited that anytime soon, we would be resettled in America. So what am I going to tell them?

The next day I went home, and I kept quiet at first. I was like, “Let me first be okay; then I can talk to them.”

I said, “Naima and Malyum, do you know what? The new president that the American people have chosen, he is a guy who doesn’t like refugees. I don’t know how our case will be processed. I don’t know if we’re going or not.”

How Trump’s win changed her view of America

I wondered, “What happened to the American people?” Because most of them that I meet, they’re nice people, they’re so friendly. And it’s America that makes the largest donations to the UNHCR. They’re the main people who provide food, everything for the refugees. I wondered how they could choose such a person.

So I asked an American friend of mine: “What is going on with your people?”

She said, “It’s a question many of us have been asking,” and she tried to explain to me: “People got tired of the Democrats. They wanted a change — it’s not Trump they voted for; they voted because of the parties.”

That made sense to me.

When Trump announced his refugee ban in late January, her fears were realized

I found out about the ban from reading the online news on my phone. At the same time, my friends from America were texting and calling. They knew I was almost there; they were waiting for me. They kept on calling: “Istarlin, Istarlin, I’m sorry.”

I thought, “Maybe I’m the unluckiest person in this world. Every time my things work out, something will happen.”

I just felt bad the whole night. I couldn’t sleep.

The next day, I had more messages from my friends in America. They said, “Istarlin, don’t worry! We’re going to fight this ban. We as American people, we own the country. It’s not his country; it’s our country. We will fight this ban, and nobody is on his side.”

I was like, “It’s okay. If I’m meant one day to come to America, then I will come. If it’s not, it’s not.”

Her daughters ask when things are going to change — and she doesn’t have an answer

If it were just me, I would try to forget. But the kids keep on reminding me, “Mum, when are things going to change?”

Sometimes you don’t have an answer. You pretend you never heard that question; you try to dodge the subject and talk about something else. But the girls are too smart for that. They keep on asking.

“I just asked you a question, what’s up with our case, is there anything new, are we really going?”

The elder one says sometimes, “You know what, Mum, I think I should stop thinking about this.”

Then I tell her, “Yes, that’s for the better.”

But the smaller one doesn’t understand that. She keeps on asking me, “Mum, when are we going, are we ever going? Or maybe we’re going to stay in Kakuma forever. I don’t like Kakuma. Kakuma is not a nice place to be.”

I tell her, “In life, you have to be patient.”

She says, “Okay, Mum, I’m a big girl. I’ll be patient.”

I say, “Okay, that’s good for me.”

Abdi Halane looks out over Kakuma camp from Kalemchuch Hill. Asked what she sees when she thinks of a life in the United States, she said, “I see myself and the girls happy. Life won’t be easy, but as long as we have each other it will be perfect. I will drop them to school, I will work and pay our bills. I want to study as well. Life won’t be luxurious, but it will fit our simple way.”

Editor: Eleanor Barkhorn
Photographer: Kainaz Amaria
Copy editor: Tanya Pai
Project manager: Susannah Locke


First Person is Vox's home for compelling, provocative narrative essays. Do you have a story to share? Read our submission guidelines, and pitch us at firstperson@vox.com.

The Supreme Court’s travel ban ruling hits refugees with terrifying uncertainty
June 26th, 2017, 07:20 PM

In 72 hours, President Donald Trump will be allowed to enforce his travel ban — but the Supreme Court made a key modification to his order that has left a big question mark over the status of refugees applicants from the six restricted majority-Muslim countries.

The Supreme Court ruled Monday that the Trump administration could reinstate its travel ban starting Thursday, but only partially: Anyone with a “bona fide relationship” with a person or organization in America will be allowed to enter, as will anyone who already has a valid visa to enter the US.

That means visa holders with family, business, or educational ties to the United States will not be affected by the executive order, as they would have been under the travel ban’s original iterations.

This, however, has left refugee resettlement organizations in flux. There is no clear language on what counts as a “bona fide relationship” for refugees: Does having contact with American resettlement agencies like World Relief or Lutheran Social Services count? How early in the refugee application process would these American entities have to have been in contact?

“We’re still trying to fully understand what this decision from the Supreme Court will mean, as the specific ramifications do not seem entirely clear from the language of the order,” Matthew Soerens, US director of church mobilization for World Relief, said over email. “We’ll be looking for how the State Department is going to interpret this.”

But it’s ultimately up to the Trump administration’s interpretation of the Supreme Court ruling. The Department of Justice, Department of Homeland Security, and State Department have yet to pass judgment — and should they have a harsh reading, it could lead to even more litigation ahead.

“With this administration, you can’t take anything off the table because of just how inconsistent the implementation has been,” Justin Cox, staff attorney with the National Immigration Law Center, said.

Refugee programs have a case that the travel ban shouldn’t impact them — but who knows what the administration will say

Cox made the case that refugee applicants from Iran, Libya, Somalia, Sudan, Syria, and Yemen that are being processed through American resettlement programs should not be impacted by the ban.

“I don’t see any wiggle room whatsoever,” Cox said. “We should get in just as many refugees.” He specifically pointed to the refugees that are the plaintiffs in the International Refugee Assistance Project v. Trump case the Supreme Court has agreed to take up in October. The lawyers “have bona fide relationships with these individuals — they are suing the president.”

According to Cox’s interpretation, American refugee resettlement programs too have a strong enough relationship with their applicants to counts as “bona fide” ties.

Of course, there are some refugees who would not meet the criteria under the Supreme Court’s guidance. There is a large contingent of refugees who go through application processes with international organizations like the United Nations Human Rights Council and are then eventually referred to the United States; they would not have American ties.

Even so, most of those applicants are so far back in the resettlement pipeline that “although it may slow the processing of their refugee applications, they weren’t going to be getting in during the next 120 days anyway,” Cox said.

Nonetheless, refugee organizations are worried about what this ruling means. Kate Melloy Goettel, litigation attorney at National Immigrant Justice Center, said her organization, which works with refugees already in the United States, is concerned with how this might affect incoming applicants. Everything is speculation right now, she said.

“There is a big question here,” Melloy Goettel said. “Refugee applicants are the group that will really be harmed in this situation.”

The Better Care Reconciliation Act: the Senate bill to repeal and replace Obamacare, explained
June 26th, 2017, 07:20 PM

Senate Republicans on Thursday revealed the Better Care Reconciliation Act, their plan to repeal and replace the Affordable Care Act.

The bill asks low- and middle-income Americans to spend significantly more for less coverage.

The bill would roll back the Affordable Care Act’s expansion of the Medicaid program, which currently covers millions of low-income Americans, and include additional cuts to Medicaid. It would rework the individual market so that enrollees get less financial help to purchase less generous health insurance with higher deductibles.

Here is how the Senate bill works:

  • The Senate bill begins to phase out the Medicaid expansion in 2021 — and cuts the rest of the program’s budget too. The Senate bill would end the Affordable Care Act’s expansion of Medicaid to millions of low-income Americans. This program has provided coverage to more Americans than the private marketplaces
  • It would also cut the rest of the public insurance program. Better Care would also limit government spending on the rest of the Medicaid program, giving states a set amount to spend per person rather than the insurance program’s currently open-ended funding commitment.
  • The Senate bill provides smaller subsidies for less generous health insurance plans with higher deductibles. The Affordable Care Act provides government help to anyone who earns less than 400 percent of the federal poverty line ($47,550 for an individual or $97,200 for a family of four). The people who earn the least get the most help. The Senate bill would make those subsidies much smaller for many people, and only provide the money to those earning less than 350 percent of the poverty line ($41,580 for individuals and $85,050 for a family of four). The Senate bill will tether the size of its tax credits to what it takes to purchase a skimpier health insurance plan than the type of plans Affordable Care Act subsidies were meant to buy. Essentially, these tax credits buy less health insurance.
  • The Senate bill seems to allow states to opt out of Obamacare’s marketplaces and essential health benefits requirement. A new waiver process would allow states to overhaul their insurance markets, including ending the essential health benefit requirement and specific subsidies that benefit low income Americans, so long as those changes do not increase the deficit.
  • The Senate bill repeals the individual mandate — and replaces it with a six-month waiting period. The bill gets rid of the Affordable Care Act’s unpopular requirement that nearly all Americans carry health coverage or pay a fine. The most recent version of the proposal includes a six-month waiting period for those who want individual coverage but have had more than a two-month break in coverage in the last year.
  • The bill would cut taxes for the wealthy. Obamacare included tax increases that hit wealthy Americans hardest in order to pay for its coverage expansion. The AHCA would get rid of those taxes. Obamacare was one of the biggest redistributions of wealth from the rich to the poor; the AHCA would reverse that.
  • The Senate bill defunds Planned Parenthood for one year. This would mean Medicaid patients could no longer seek treatment at Planned Parenthood clinics. Experts expect this would result in low-income Americans getting less medical care and having more unintended pregnancies, as access to contraceptives would decline.
  • All in all, the replacement plan benefits people who are healthy and high-income, and disadvantages those who are sicker and lower-income. The replacement plan would make several changes to what health insurers can charge enrollees who purchase insurance on the individual market, as well as changing what benefits their plans must cover. In aggregate, these changes could be advantageous to younger and healthier enrollees who want skimpier (and cheaper) benefit packages. But they could be costly for older and sicker Obamacare enrollees who rely on the law’s current requirements, and would be asked to pay more for less generous coverage.

The Senate bill will end Medicaid expansion in 2021 — and cut the rest of the program too

One of the main ways Obamacare increased insurance coverage was by expanding the Medicaid program to cover millions more low-income Americans. Prior to the health law, the entitlement was restricted to specific groups of low-income Americans (pregnant women, for example, and the blind and disabled).

Obamacare opened up the program to anyone below 138 percent of the poverty line (about $15,000 for an individual) in the 31 states (plus the District of Columbia) that opted to participate.

The Medicaid expansion gave states generous funding to cover this particular population. Typically, the federal government picks up about half the cost of the Medicaid program and states cover the rest.

For Medicaid expansion, however, the federal government currently pays 95 percent of the costs — an especially good deal for states meant to assuage their budget concerns during the original Obamacare debate.

The Senate bill would begin ratcheting down that Medicaid expansion funding in 2021. By 2024, states would get that same match rate they typically get to cover other populations. In 2021, for example, the match rate would fall to 90 percent, then decline in steps to 75 percent by 2023.

The Congressional Budget Office has projected in a separate analysis that this policy change would mean no additional states expand Medicaid — and that some current expansion states would drop out of the program, resulting in millions losing coverage.

“CBO anticipates some states that have already expanded their Medicaid programs would no longer offer that coverage,” the agency wrote in its analysis of the House bill, which makes a similar change.

The Senate bill would cut the rest of the Medicaid program too

There are significant changes to Medicaid in the Senate bill outside of the expansion too. This bill would convert Medicaid to a “per capita cap” system, where states would get a lump sum from the federal government for each enrollee. Or states would have the opportunity of a block grant — a sum of money untethered from the number of people involved.

This is very different from current Medicaid funding. Right now the federal government has an open-ended commitment to paying all of a Medicaid enrollee’s bills, regardless of how high they go.

The Senate bill would set different amounts for different groups of people. It envisions, for example, likely higher payments to cover Medicaid enrollees who are disabled (and tend to have higher costs) than Medicaid enrollees who are kids (generally healthy with lower costs).

The rate at which these payments grow is also important. The Senate bill would have the funding growth tethered to the Medical Consumer Price Index plus 1 percentage point through 2025, and then switch to the urban Consumer Price Index. Analysis of this type of proposal suggests this change would amount to funding cuts for Medicaid, as the program’s spending typically goes up faster than these growth rates.

We do not know exactly how much this bill would cut the Medicaid program because we are still waiting on an analysis from the CBO, which is expected to be released early next week.

The Senate bill would cut the subsidies for people on the individual market

The Affordable Care Act provides financial help to low- and middle-income Americans who purchase their own health coverage. It provides subsidies to people who earn less than 400 percent of the federal poverty line ($47,550 for an individual or $97,200 for a family of four) and gives the most generous help to people who earn the least.

For example: People who earn $17,000 are only expected to spend 3 percent of their income on premiums for a midlevel insurance plan — the government will kick in the rest. People who earn $40,000, however, are expected to spend 9.66 percent of their income on those monthly payments.

The Senate bill would overhaul these tax credits. It would make fewer people eligible for the help, limiting the subsidies to people who earn less than 350 percent of the poverty line ($41,580 for individuals and $85,050 for a family of four).

It would also allow people who earn less than the poverty line to qualify for tax credits; the Affordable Care Act makes those people ineligible for the subsidies because they were expected to receive coverage through the Medicaid expansion.

This became problematic, however, when the Supreme Court ruled that the Medicaid expansion had to be optional and 19 states decided not to adopt it. So this change would be an improvement for low-income Americans who live in places like Texas and Florida, which did not expand the program. They currently have access to no subsidies under the Affordable Care Act.

It would also change the definition of what counts as “affordable” health insurance to amount for a greater chunk of Obamacare enrollees’ income. Right now the Affordable Care Act counts health insurance as “affordable” if it costs less than 9.7 percent of an individual’s income (and a lower amount for lower-income Americans). You can see the table here:

The Senate bill would raise the amount individuals are expected to kick into their health plans for people who are low to middle income. A 60-year-old who earns $35,640 (300 percent of the poverty line) would be expected to spend 16.2 percent of her income ($5,773) before she gets any help from the government. You can see the chart that spells this out here:

Under the Affordable Care Act, she would only be expected to spend $3,442.

The Senate would subsidize less generous insurance. Under the health care law, the size of the tax credit is tethered to how much it costs to buy a midlevel health plan. The Affordable Care Act defines “midlevel” as a plan that, on average, covers 70 percent of enrollees’ costs. In insurance terms, this number is known as the “actuarial value,” and it’s used to give a sense of how much the typical enrollee pays out of pocket for coverage.

The Senate bill would tether its tax credits to less generous health insurance. Specifically, it would provide subsidies that make a plan with a 58 percent actuarial value (meaning, on average, it covers 58 percent of enrollees’ costs) affordable.

This means that the plans people could afford under the Senate bill would likely have more copays and higher deductibles as a way to bump up the amount enrollees have to chip in for their own coverage. Someone who has earnings right around the poverty line (about $12,000) would still be expected to spend 2 percent of her income on premiums. But in return, she’d get a health plan that covers less than what she gets under the Affordable Care Act.

The Senate bill would also bar Americans from using their tax credits to purchase a health plan that covers abortion. This requirement would take effect immediately, while other changes would not phase in until 2020.

The Senate bill allows states to opt-out of big Obamacare provisions, like the requirement to cover essential health benefits, through a re-vamped waiver process

The Senate bill overhauls a section of the Affordable Care Act that allows states to experiment with different ways to provide health insurance coverage. Under current law, states are allowed to propose different ways to deliver health insurance so long as the new plans “provide coverage that is at least as comprehensive as the coverage” defined under the ACA” and “cover at least a comparable number of residents.” In other words: as long as states can cover the same number of people with a similar plan, they’re allowed to experiment with things such as single-payer health care.

The Senate bill would allow states to seek waiver from key Obamacare requirements, things like the essential health benefits package, which requires health plans to cover key services like maternity care and prescription drugs. But the Senate bill would not require these new plans to cover as many people or provide comparable plans. It eliminates those requirements, and says states can get waivers as long as they don’t increase the deficit.

You can see the language that gets removed in this helpful tweet:

Under these requirements, a state could ask for a waiver to allow insurers to longer cover things like maternity care or mental health services — two things that individual plans often left out before the Affordable Care Act mandates. They would not be bound by the current Affordable Care Act requirement that coverage under these waivers be just as generous as the standard plans.

The Senate bill eliminates the individual mandate — and replaces it with a six-month waiting period to penalize the uninsured

One of the Affordable Care Act’s least popular provisions was the requirement that nearly all Americans carry health insurance coverage or pay a fine. The reason this mandate existed was to convince healthy people to buy health insurance, which would hold down premiums for everyone else.

The Senate would eliminate the individual mandate by setting the penalty for not carrying health insurance to zero dollars. They can’t completely wipe it off the books due to the complex rules of the budget reconciliation process, but this would have the same effect.

The Senate bill replaces the individual mandate with a six-month waiting period for those who fail to maintain continuous health insurance coverage. Specifically, this means that those with a break in coverage longer than 63 days would have to wait at least six months from the date they file an application for health coverage to enroll in a plan. This is on top of the health care law’s open enrollment periods, which would still exist under the Senate plan.

The six-month waiting period fills a big policy gap in the first draft of the Better Care Reconciliation Act, which required health plans to accept all patients — but didn’t require all Americans to purchase coverage, as the Affordable Care Act does. Experts expected that this would cause a death spiral, where only the sickest patients purchase coverage and premiums skyrocket.

The new six-month waiting period aims to fix that problem. It is meant to nudge healthy people into purchasing coverage because they may fear the consequences of getting locked out of the market down the road.

The Senate bill repeals a long list of Obamacare taxes

The Senate bill will eliminate many of the taxes that financed the Affordable Care Act’s insurance expansion. It includes the repeal of:

  • A tax on investment income
  • A tax on the wealthy to finance the Medicare program
  • A tax on tanning salons
  • A tax on the health insurance industry
  • A tax on the medical device industry

Many of these tax changes would, as my colleagues have previously written, disproportionately benefit high-income Americans.

“The typical American, in short, isn’t going to see any money from these tax cuts,” Matt Yglesias has written. “But when you take all that money out of the system, something has to give. And in the case of the various iterations of Affordable Care Act repeal, the thing that gives is the quality of health insurance provided to Americans with below-average incomes or above-average health needs.”


Join the conversation

Are you an Obamacare enrollee interested in what happens next? Join our Facebook community for conversation and updates.


The Senate health bill: poor people pay more for worse insurance

Trump’s travel ban is about to go into effect. Here’s why it’s immoral.
June 26th, 2017, 07:20 PM

A political theorist on the ethics of Trump’s "Muslim ban"

Six months ago, President Donald Trump signed an executive order shutting out refugees and halting visas from six Muslim-majority countries. But that ban was never implemented, thanks to rulings in two separate federal courts.

That changed on Monday.

The Supreme Court ruled that the Trump administration should be permitted to enforce the ban starting on Thursday, June 29. The court did impose some restrictions on the ban, however, including allowing people who already have a valid visa to enter the country.

The ban on refugees remains, though. Refugees will not be allowed to enter America for a period of 120 days — unless they’ve already been issued a visa or have a “bona fide relationship with a person or entity in the United States.”

Below is an interview I conducted back in January with Joseph Carens, a professor of political theory at the University of Toronto and a dual citizen of Canada and the United States. The author of The Ethics of Immigration, Carens’s work focuses on the challenges involved in applying democratic principles to immigration policies.

Here, I spoke with Carens about the ethics of Trump’s executive order as well the normative questions it raises about human rights.


Sean Illing

What do you see as the basis of our moral obligations to admit refugees?

Joseph Carens

I think there are at least three overlapping bases for these obligations. The first is that the US is sometimes responsible for the fact that someone has become a refugee. For example, people in Iraq and Afghanistan who have helped American forces by serving as translators or in other capacities have sometimes been put at risk because of this service. There are already stories of such people being excluded from admission (and hence, safety) as a result of Trump’s policy.

The second basis for the obligation to refugees is simply the humanitarian duty to help people in desperate straits when one can do so. This duty has its roots in many different religious and secular ethical traditions. The United States has traditionally admitted more refugees than any other country (although Germany has clearly passed the US in this respect in the past few years). The complete ban on refugee admissions for four months and the subsequent reduction (by half) of the number who will be accepted is a failure to meet America’s humanitarian obligations.

The third basis for the obligation to refugees is that the United States and most other countries have acknowledged that the international state system has a duty to protect refugees. In the wake of the failure of democratic states to protect Jewish refugees from the Nazis, the United States led the effort to create institutions that would prevent such a moral failure in the future. That regime already suffers from severe limitations, and the new Trump policy will undermine it further.

Sean Illing

What are the moral limits on what states can do to individuals in a democratic society, and why is the answer to that question relevant to thinking about immigration policy?

Joseph Carens

I'd say that we have principles that everyone recognizes. For example, people have a right to a fair trial, to freedom of religion, to freedom of speech, to freedom of movement. Now, many of these things are put into the Constitution and the Bill of Rights, but there are overlapping rights that are freestanding norms that we have about how you can treat people or what it's reasonable for the government to do. These are basic norms of fairness and reciprocity, principles that we hold to be transcendentally true.

Sean Illing

I’ll stop you there for just a second and ask an obvious question: What do these norms and rights have to do with immigration in particular? I imagine many people will associate these rights with citizenship, or membership in a defined polity.

Joseph Carens

Well, this includes norms about how you can treat noncitizens. People sometimes think that all rights are due to citizenship, but that's just not correct in the empirical or legal or normative sense. So take the right to a fair trial. If you're a noncitizen and you're accused of a crime, you're supposed to be treated exactly the same way a citizen is. You have the same rights that a citizen does in this area. In fact, permanent residents have virtually all the rights that a citizen has except for the right to vote.

Sean Illing

In your book, you say that contemporary reflection about refugees begins in the shadow of the Holocaust. Countless Jewish people fled Hitler in search of protection, and most of them did not get it. Do you see Trump’s executive order banning the entry of all refugees for 120 days and those from Syria indefinitely as analogous in any way?

Joseph Carens

Absolutely. I think this is a point that's been made by a number of Jewish groups who are trying to welcome Syrian refugees. It's an irony, as many have noted, that this policy was announced on Holocaust Remembrance Day. At the time of the Holocaust, there were lots of Jews trying to flee Nazi Germany, and many Western states, including America and Canada, refused to accept them.

President Trump's answer to the question of how many Syrian refugees are too many seems to be "none." None is too many. In the wake of World War II, in the wake of seeing what happened, we vowed never to let that happen again, and that's exactly what we're doing in the case of Syria.

These people's lives are at stake, and if the United States turns them away, why do we assume other countries will take them in? And if no one else takes them in, what do we think will happen to them?

Sean Illing

There’s a lot of discussion about the legality of Trump’s executive order, but here I’d like to dive into some of the deeper ethical objections. I’ll start with this: Do you think this policy will produce more suffering than it relieves?

Joseph Carens

The goal of the policy is to reduce the threat of terrorism, but many objectors (rightly) think that the policy’s actual effect will be to increase the threat of terrorism because it will alienate Muslims throughout the world and will confirm the claim of ISIS that the United States is fundamentally hostile to Islam, but it won’t actually aid in preventing the entry of people who might pose a threat.

This is an important, and, in my view, persuasive argument about the likely consequences of the policy, and so a good reason for rejecting it, but it is an ethical argument only in the very limited sense that any policy that causes more harm than good with respect to a legitimate goal (like reducing the threat of terrorism) can be said to be bad from a moral perspective.

Sean Illing

What about the claims that it runs counter to fundamental American values?

Joseph Carens

Openness to immigrants and refugees has played a key role in making the United States what it is today and is a central element in the American ideal. This need not entail denying the reality of practices of marginalization and exclusion of immigrants and refugees at many points in the American past. Rather, it reflects a commitment to live up to the ideal and not to repeat those failures.

This sort of objection to Trump’s policy focuses on values and ideals, and, in that respect, it is clearly a moral argument. On the other hand, within some limits, deciding what you want your country to be is clearly the sort of thing that democratic politics is supposed to be about.

Sean Illing

Perhaps the most essential moral objection is that a policy like this violates basic principles that are supposed to limit or constrain democratic politics. Here I’m thinking of principles of justice, fairness, equality, and individual freedom.

Joseph Carens

I think this policy does that in two obvious ways.

First, in imposing restrictions on entry that take immediate effect, it violates norms of fairness. As everyone knows, the policy has stranded people abroad who had already been living in the United States as well as people who had been given permission to come and had made life plans on that basis. To deprive people of a right to enter the United States that they had previously been granted and which they have done nothing to forfeit is unfair.

The Trump administration has already implicitly acknowledged this moral failure in changing the policy so that it no longer restricts the entry of green card holders (i.e., people entitled to live in the US as permanent residents), but this still leaves a great many people who have done nothing wrong stranded abroad with their lives disrupted. For example, students cannot get in to continue or start their studies, workers with permits other than green cards cannot return, and so on. These exclusions are simply arbitrary.

Second, the policy violates the moral principle that it is wrong to discriminate on the basis of religion. The seven states whose citizens are not permitted entry are all overwhelmingly Muslim. Trump himself has implicitly acknowledged that it is wrong to discriminate on the basis of religion by denying that he is doing so. This recalls the old saying that hypocrisy is the tribute that vice pays to virtue. In this case, however, the hypocrisy is so blatant, given Trump’s past and present statements about Islam, that no one who cares about reality can take his protestations seriously. This policy is clearly and deliberately aimed at restricting the entry of Muslims.

Sean Illing

Why is the distinction between migrants and refugees so important, and why do refugees have a stronger claim upon host societies for aid and sanctuary?

Joseph Carens

Migrants are people who want to move from one country to another. They may have good reasons for moving or bad reasons for moving. Refugees are people who have a desperate need to move: They're not safe in some fundamental way and they need to leave. So their claim to move is much stronger, and we all recognize that. The United States has signed the Geneva Convention on refugees. Even Trump doesn't deny that refugees have some kind of claim, he's just not willing to meet it. He's concerned about those who are suffering and desperate, but he's not prepared to say what he will do to help them.

Sean Illing

What rights do states have to determine that accepting or admitting refugees imposes unsustainable burdens or risks on their society?

Joseph Carens

Nobody thinks that states have to admit people who actually are terrorists, and so it's reasonable for a state to do some vetting. Nobody thinks a state should admit so many refugees that it cannot function. But in a lot of cases, this involves what one thinks is a reasonable assessment.

So the idea that because someone might be a terrorist, or there's a tiny chance that someone's a terrorist, is not in itself a justification for shutting the doors. There has to be some kind of balance in terms of the judgments we're making. Reasonable people can disagree about what that balance is, but the extreme standard that Trump is using is well beyond the standards of reasonableness.

Sean Illing

There seems to be a problem of distributive justice here in which the burdens of accepting refugees are not dispersed equally across the nations of the world. How do we deal with that given the limits on interstate cooperation?

Joseph Carens

That's an important issue, and there isn't a structural solution to that, there's nothing that can make a state accept refugees. So if the United States refuses to do, there is no one that can force us to do it. But that's a question that every American should ask himself or herself: If we don't take in these refugees, who is going to do it? And why do we think it's reasonable to expect them to do it if we won't? It seems to me that nobody is asking that question.

Right now there are millions of Syrian refugees in countries like Jordan and Turkey and Lebanon, and these are not countries that have caused this crisis in any way. They have no particular responsibility for these refugees, except for the fact that they're next door. But there's no reason to expect these countries to provide new homes for all of these refugees for the rest of their lives, and there's no sign that this conflict will end anytime soon.

Here's the thing: How many people actually ask themselves what will happen to these refugees if we don’t take them in? I think a lot of people blind themselves to this question. They're not willing to contemplate the consequences of refusing entry to these desperate people, and that’s part of the problem.