Iowa Is Ground Zero for the Republicans' Disastrous Approach to Healthcare

By Charles Pierce, Esquire

09 April 18

Street-'surance and Medicaid privatization do not make a pretty picture.

orry to harsh your Monday mellow, but there are politicians skulking around Iowa these days, and they’re not there for the spring planting. Unless you count the planting of the idea that one of them should be President of the United States, and, yes, it’s 20-bloody-18 and why should that matter anymore?

Jason Kander, the Democratic former secretary of state in Missouri, has been out there 14 times, and his first trip was a little more than a month after the 2016 election. Eric Swalwell, the California congressman who’s on TV every week more than Jack McCoy, spent last weekend touring Ames, Des Moines, Cedar Rapids, and Muscatine, while Steve Bullock, the governor of Montana, was kicking around Polk County as well. We are not at the swinging-a-dead-cat portion of our program yet, but it’s coming up fast. Plan your visit to this year’s State Fair now. The line for the Butter Cow is probably already around the block.

Meanwhile, among the people who live in Iowa fulltime, Governor Kim Reynolds and the state legislature are going out of their way to make more difficult the lives of Iowans who need healthcare. First, in an example of what healthcare expert Charles Gaba calls “medical gerrymandering,” the legislature went out of its way to make sure every Iowan has a chance to buy completely worthless insurance that very likely will not help them at all if and when they get sick. From The Des Moines Register:

Supporters contend Senate File 2329 would create a much-needed, low-cost option for Iowans who can no longer afford rising premiums and out-of-pocket costs on the individual insurance market. "All we're trying to do is help those who can't find insurance," said Sen. Randy Feenstra, R-Hull. Feenstra said anyone excluded from the new plans because of a pre-existing health problem could go and buy policies from a carrier offering insurance that complies with the Affordable Care Act. But for others, he said, the new plans would offer a less expensive option. But critics fear the change would further destabilize Iowa's already fragile health insurance market and undermine Affordable Care Act rules designed to protect consumers."We're going to be throwing a soggy life jacket to people that need our help," said Sen. Joe Bolkcom, D-Iowa City…several Democrats noted the new coverage would technically not be defined as health insurance, and would not be regulated by Iowa's insurance commissioner. "This just doesn't pass the smell test," said Sen. Matt McCoy, D-Des Moines.

So now you can buy health insurance that not only doesn’t cover you if your health goes bad, you can buy health insurance that isn’t even called health insurance.

And the level of obliviousness on which the debate was conducted is best exemplified by something said by one of the state legislators who jumped on the street-‘surance bandwagon. Again, from the Register:

Sen. Mark Chelgren, R-Ottumwa, defended the legislation, saying it is an example of how health care was provided before Congress enacted the Affordable Care Act. "We have tried this before. This was how the system worked. In the past, we gave people choice. We said, 'We trust you with your health care decisions,' " Chelgren said.

Is this the next weapon in the fight against having this country join the rest of the industrialized world? Nostalgia for the way things used to be? For the system that was so bad that it was killing 40,000 people a year? For the system that was so bad that Mitt Romney begged a new plan out of the Massachusetts legislature because he knew the Republicans had to have some answer to the broken healthcare system in 2008, when he was planning to run for president? Remember when being a woman was a pre-existing condition? Boy, as Mr. Dooley said, thim was the days!

Meanwhile, at the same time, Iowa is also serving as the test-track for the Medicaid system with which Paul Ryan wants to bless the nation. This is not going well, as the Register explains.

The casualties are patients like 4-year-old Tatum Woods of Vinton, Iowa, who for nearly six months was forced to crawl because a private Medicaid provider said it would pay less than a fifth of the cost of his $3,500 customized walker. It’s an experience multiple officials and lawmakers contend is widespread in Iowa, and it's driving Medicaid patients and their families to new depths of frustration. “These kids shouldn’t have to fight to get their equipment," said Kristie Woods, Tatum's mother. "They’ve already got enough struggles." At issue is the reimbursement rate the private companies that manage Iowa’s $4.8 billion Medicaid program are paying to medical equipment providers for specialized equipment. Medical device providers say Iowa's privatized Medicaid managers are willing to pay only pennies on the dollar — if anything at all — for the medical devices that doctors are authorizing for their disabled patients. It's another example of what critics say is Iowa's flawed Medicaid system since then-Gov. Terry Branstad turned over management to for-profit companies in April 2016 in an attempt to save money and in his view improve care.

Right. It was all about saving money. Let’s not pretend we all came to Vinton on a turnip truck.

Officials from Total Respiratory and Rehab in Hiawatha said Amerigroup classified Tatum’s equipment as a “miscellaneous” expense, capping the maximum reimbursement at less than 20 percent of its cost. Total Respiratory said Tatum is one of dozens of clients it has been forced to deny equipment in the last year because Iowa's Medicaid system refused to pick up the cost. The company — and four other medical equipment providers across the state — have outlined multiple billing problems associated with the Medicaid companies that they say has resulted in underpayment by tens of thousands of dollars and forced them into denying equipment to patients who need it.

This story is part of a very good series by the Register on the consequences of privatizing Medicaid, which has brought about denial of basic needs, bureaucratic stonewalling, and corporate buckpassing.

Each of the medical equipment companies said they are experiencing problems from both of Iowa’s Medicaid management companies, Amerigroup and UnitedHealthcare. UnitedHealthcare tends to limit claims or issue blanket denials, while Amerigroup incorrectly codes and underpays, they contend. “They’re trying to reimburse us well below our cost,” said Jon Novak, CEO of Total Respiratory. “If we dispense the equipment at this cost, we would go broke.”

In short, it’s brought back all the highlights of the American healthcare system for which some Iowa legislators seem so damn nostalgic. This is the next fight and, as silly as it sounds, they mean to bring us back to the system that everybody knew had failed. Forward, as the Firesign boys used to say, into the past.

Democrats Shouldn't Give in to White Racism

By Jamelle Bouie, Slate

09 April 18

The idea that the Democratic Party should back off its commitment to civil rights is as misguided as it is ugly.

oo many observers treat American politics as a contest between rival groups of white people. It’s how you get dubious claims that Donald Trump broadly represents “working-class” voters, or the related narrative that pits a monolithic “coastal elite” against a so-called “heartland,” ideas that cannot survive contact with any consideration of black political behavior. The result is that black Americans and other groups—which represented nearly 27 percent of the electorate in 2016, more than 36 million voters—get erased from mainstream political discourse and are ignored as full citizens and political actors.

But focusing on white political conflict doesn’t just remove blacks and other nonwhites from the state of national politics. It also obscures the racial dimensions of white politics, rendering invisible the historic interest—across much of white society—in preserving white racial hegemony.

Writer James Traub does something akin to this in a piece for the Atlantic that takes a critical view of the Democratic Party’s mid-century embrace of racial liberalism, in which the party “exchanged a politics of self-interest for a politics of moral commitment,” asking its white supporters in the suburbs and cities to sacrifice for the sake of civil rights. Traub doesn’t fully obscure white voters’ racial interest. Instead, he minimizes its scope and holds it out as essentially understandable, something that liberals should accommodate as they move forward from the present moment.

Traub recounts the career of Minnesota Democrat Hubert Humphrey, whose efforts brought racial liberalism to the Democratic platform and sparked a revolution that culminated in Lyndon Johnson’s dramatic push for civil rights legislation in the 1960s, nearly 20 years after he opposed Harry Truman’s attempt to end the poll tax as a candidate for Senate.

Traub has his history right. Johnson’s push was the beginning of a process that split the Democratic Party from the bulk of white America, setting up the conservative counterrevolution of the 1970s and 1980s. But he sympathizes with those, especially in northern cities, who resented Democratic efforts to integrate their schools and neighborhoods. “It was a lot to ask, especially outside the South, where whites did not feel complicit in a legal system of racial separation (even if they should have felt complicit in a de facto system).”

Traub wants to put an asterisk next to the civil rights gains of the 1960s, asking liberals to consider the costs of their choices in 1948 and 1968, given the fact of a white backlash so potent it put Donald Trump in the White House. “The sense of superior moral standing that liberals derived from defending the rights of the marginalized often blinded them to the effect of their policies on white Americans (and at times on the marginalized themselves).”

What’s striking, in all of this, is that Traub is building toward a conclusion—that liberals, in the future, should tread carefully as it regards the rights of racial (and other minorities)—which he won’t say outright. But rather than make the point directly, he hedges around it, letting readers make the implication. “Trump voters also may have reason to feel that something precious is being taken from them. Maybe it behooves today’s Democrats to take those grievances more seriously than they’re inclined to.”

Whether you grasp that implication depends on whether you understand what Traub means when he says “something precious.” It’s connected to an earlier point in the essay, where he writes that “Once the Great Society began to confer rights and privileges on black people beyond the Jim Crow South, whites who, whatever the truth of their behavior, had no consciousness of having kept blacks down began to feel that their abstract commitment to the cause of civil rights carried a very real cost.”

The cost and the object are the same: white racial hegemony. And far from having no consciousness of keeping blacks down, by the 1960s, northern whites had a recent history of anti-black policy and practice reinforced by anti-black violence. Traub depicts whites outside the South as largely innocent actors pushing back against liberal overreach. But the segregation that made busing necessary—which he attributes to blacks and whites simply “living far apart”—was built just decades earlier by white bankers, realtors, and homeowners, who enforced rigid racial lines with every tool at their disposal, backed by local, state, and often federal authorities.

None of this is apparent in the piece. Indeed, the argument depends on not having a sense of the depth of commitment to white racial dominance among many white Americans, a commitment so deep that the decades after the 1960s would see millions of whites abandon cities and other public spaces rather than back or accept integration. To counsel sympathy for this commitment and behavior, as Traub does, is to acquiesce to dynamics of racism that entrench disadvantage, increase inequality, and weaken the movements that aim to ameliorate both.

Above all, Traub’s argument treats the lives and livelihoods of black Americans (and other marginalized groups) as immaterial. Civil rights for blacks or any person of color bears no consideration on the merits. The limits of justice are what whites will tolerate, and if most whites won’t move, then liberals shouldn’t push.

Because of that, Traub’s essay is emblematic. Not just of its genre—the post-2016 push against “identity politics” from writers like Mark Lilla and Andrew Sullivan—but of a larger tendency in American political thinking. One that puts race on the sidelines and treats American politics as a parlor game, with nonwhites as a bargaining chip in a negotiation between white people.