Uninsured pay the price for ACA reform failure

On Election Day, Maine holds a popular vote on whether to expand Medicaid. No other state has done that.

The expansion would cover an estimated 70,000 people who don’t have health insurance. The decision embodies two key elements of most government actions: there’s no free lunch and nothing is decided once and for all.

After the Affordable Care Act was passed, the Supreme Court ruled that the federal government could not force states to cover more people under Medicaid, even when the feds paid about 90 percent of the cost. The ACA would have withdrawn existing federal payments if states did not accept expansion.

That decision left it up to the states to decide on voluntarily accepting expansion. Though 31 states plus D.C accepted, 19 did not. Maine resisted expanding its Medicaid, called MaineCare, the only northeastern state to reject increased coverage.

The Maine Legislature voted six times to accept the expansion, but Gov. LePage vetoed the bill each time. The issue comes to the voters because of a citizen initiative, which could not be vetoed.

LePage not only sees expansion as “welfare,” but dislikes its budget impact. It would cost the state less than $55 million, and each state dollar would bring $9.63 in federal dollars. Under the non-controversial highway referendum, Question 3, each state dollar would bring $1.10 from the feds.

Without the expansion, people who would have been eligible must continue getting haphazard medical care by relying on emergency rooms. The cost of their care is rolled into hospital costs and recovered in higher charges. Insurance premiums rise to handle the increases.

All the money comes out of people’s pockets, but we have little idea how much of the state spending would be offset by lower hospital costs and insurance premiums. LePage looks at the state budget not the individual’s wallet.

But increasing the number of people with health insurance coverage inevitably costs more. That’s why the ACA raised taxes on the wealthy. Still, there’s no way to be sure just what the net cost is.

So the vote comes down to whether Mainers want to risk a higher net cost to help more of their neighbors get better medical care. That is a classic political decision, involved in every budget action in Washington or state capitals.

Does the community, through its government, want to pay more to do more? If keeping the budget down is the highest priority, as it is for LePage, then his answer is “no.” Now it’s up to voters to give their answer.

This kind of decision must be made over and over on everything done by any government, from military spending to medical care. Only rarely do the voters find themselves deciding the answer.

LePage has another concern. Once Medicaid is expanded, how sure can we be that the federal government will keep up its end of the bargain? Perhaps years down the road, it will decide to change the funding formula, leaving states to pick up more Medicaid costs.

To avoid that risk, voters would have to turn down Medicaid expansion. This a reasonable issue to consider.

It’s like current proposals for tax “reform,” with cuts proposed that would reach out at least 10 years. No Congress binds another on most matters, so tax cuts could well be revoked sooner than promised.

In a democracy, people get to change their minds, especially in changed circumstances. If worry about possible change were allowed to control, not much would happen.

Still, it is worth worrying about programs like Social Security, Medicare and Medicaid that weigh heavily in the budget, but whose costs are driven by participant eligibility not budget priorities.

The answer may not be to deny people help they need because of such worries, but to address the underlying problem directly and comprehensively. Touching these programs is considered the fatal “third rail” of politics. Most likely, the only solution will come from a nonpartisan effort.

When benefit payments are guaranteed, providers and insurers may be tempted to use the system to boost their revenues. What decisions need to be made to limit the growth in costs?

Better ways of determining eligibility and improved protection against cheating is essential. But also essential would be some method of regulating costs of quasi-monopoly health care. Now that repealing the ACA has failed, it’s time for reform.

Maybe that’s what critics will now accept. But much-needed health insurance action should not use the ill, lacking insurance and access to affordable medical care, as hostages to force reform.

Free speech under attack from right, left

President Trump and some liberal college students have something important in common.

They don’t like the statements made by others, whether professional football players or conservative writers, and they demand an end to such statements.

The reason that Trump and the students oppose free speech, even to the point of preventing a person from speaking, is fear that what others say may convince somebody of something. Even worse, such opposition may show they want to limit free speech to their viewpoint alone.

Ironically, the more free speech is opposed, the more attention the expression gets. We get to learn about why football players are protesting – government sanctioned racial discrimination - and the positions of campus speakers who are silenced – sometimes extremely conservative.

One of the characteristics of the U.S., distinguishing it from most other countries, is the First Amendment. Elsewhere, government and laws often limit what people may say. While, like any other right, government may apply some limits, the American system favors debate in the sunshine as the best way to oppose views you don’t like.

You cannot fly the Nazi flag in some European countries. Just as the Europeans, millions of Americans engaged in a war against the Nazis. But government here cannot stop you from flying a Nazi flag. You are also free to demonstrate against this display, but government cannot legally tear down the flag or stop demonstrators.

Free speech is part of the American character. Expression has always been bold and outspoken. Belief in the Constitution and our form of government is strong enough to allow Americans to tolerate dissenting or opposing views. Sometimes, over the long term, the unpopular, minority view prevails.

In fact, people take pride in displaying the strength of a system allowing unpopular dissent. One often-quoted sentence embodies the concept: “I disapprove of what you say, but will defend to the death your right to say it.”

What about outright lies? They abuse the right. Individuals affected have the right to legal action. Otherwise, free debate should expose them. For example, the Washington Post Fact Checker does an excellent job keeping tabs on political claims. It is kept quite busy.

Trump’s attacks on NFL players who “take a knee” when the National Anthem is played reflect his natural petulance, playing to his supposed core constituency, trying to deflect attention from other issues by the use of phony patriotism, or all of the above.

The president has a right to express his views. The problem is that he is not acting presidential, breaking another of his campaign promises. How football players behave when the National Anthem is played is unimportant compared with leadership in dealing with the threat of nuclear war or natural disasters.

We expect the president to unify and lead, not always to seek or, worse, create domestic conflict. He needs to use carefully his right of free speech because of his position. If he disturbs the “domestic tranquility” promised by the Constitution, we worry.

College students who try to block campus speakers, whom they believe advocate views and policies that are wrong or dangerous, are undermining their own education. Free discourse allows us all not only to hone our personal values but also to better understand opposing views.

Freedom of speech is not a First Amendment right; it is a natural right. “All people are born equally free and independent, and have certain natural, inherent and unalienable rights.... Every citizen may freely speak, write and publish sentiments on any subject....”

Those are the words of the Maine Constitution, not the U.S. Constitution. The First Amendment is part of the Bill of Rights, but it does not explicitly reaffirm the natural right of each person to free speech, as does the Maine Constitution. It bans government from passing laws “abridging the freedom of speech” of all, not only citizens.

There may be problems with this “natural right” when the Supreme Court classifies corporate political spending as speech. That means all people get free speech, but some non-people may purchase it. Big money buys big talk, which threatens to drown out opposing views.

We all have to judge what we hear and read. Decisions about matters ranging from whom we support for president to where we choose to live are all based on what we have learned.

If you don’t want to hear a speaker, don’t listen. But don’t try to close the door for others.

Freedom of speech belongs to us, as listeners, writers, readers, and speakers. It’s our natural right.

Korea: Too much saber rattling, too little talk

The public television series on the Vietnam War reveals lessons the U.S. failed to learn as it was engulfed by the struggle.

Whatever its intent, the series suggests parallels with the current North Korea crisis. A viewer comes away from the programs with impressions about what works and where to be careful.

President Kennedy and other leaders believed that, if the Viet Cong insurgents and North Vietnam were successful, Communism could spread to other countries in the region. American policy was based on helping the South Vietnamese to prevent this outcome.

What really happened in Vietnam gives us the chance to see whether those U.S. fears were correct. North Vietnam succeeded in taking over the entire country in what had to been seen as a U.S. defeat. Did the dominoes fall all over Southeast Asia?

Vietnam is now an independent country visited by American tourists and doing business with American companies. Laos and Cambodia are not Communist. In fact, while countries like China seek territorial or economic domination, their moves have nothing to do with Communist ideology.

In confrontations with other powers, American policy often focuses on the worst possible outcome and seeks to prevent and protect against its effects. Policy makers pay far less attention to possible, more positive outcomes and measures that might increase their likelihood of success.

On North Korea, our attention is centered now on the possibility that Kim Jong-un will launch a nuclear attack on the U.S. or one of our allies. When he rattles his saber, we rattle ours in return.

The U.S. appears to have little idea about what Kim wants, so we focus on what he threatens. If we try to negotiate realistically to see if we can get what both sides must really want – no war – that could be progress.

“Meeting jaw to jaw is better than war,” said British statesman Winston Churchill, an honorary U.S. citizen. If the two sides could spend as much effort on finding a way to meet as they do on warning each other about war, there might be a better chance of resolving the crisis.

Only after the two sides talked to one another did U.S. involvement in the Vietnam War wind down. The American and North Vietnamese negotiators even got Nobel Peace Prizes, though the war continued a while longer.

The America position is often that the U.S. is willing to negotiate, but only if certain preconditions are met. They are so broad that negotiations would probably become unnecessary, because the other side would have already made the desired concessions. That’s not likely to happen.

Negotiating does not ensure agreement. But proposing a jaw-to-jaw meeting between President Trump and Kim would yield some intelligence and impress the rest of the world with America’s willingness to talk. And the U.S. might be able to find out about Kim’s objectives.

How stunning would it be for the two to meet in Guam or Switzerland, where Kim once attended school? The sole precondition would be that both leaders stepped back from making threats.

Proposing such a meeting could look like an American concession. Is leaning on China, as the U.S. now does, any better? Taking the negotiating initiative could buttress America’s weakening role in Asia.

The American strategy now consists of squeezing North Korea with sanctions, hoping they can be starved into backing off their threats. But Kim is certainly willing to starve his people to save his policy and his job.

In Vietnam, American support for corrupt regimes fuelled opposition to the U.S. among the South Vietnamese. People may well turn against outsiders applying pressure affecting them and toward support of their local regime. Desperation may promote resistance to foreigners, not rebellion.

Promoting prosperity may be more of an effective American policy than starvation. As people make personal economic gains, they have an increased stake in peace.

On one program, a South Vietnamese province chief says that, if he had the cost of one U.S. helicopter, he could have pacified his province through economic development. He was turned down, and the Viet Cong began shooting down U.S. helicopters with handheld weapons. The war turned even hotter.

Kennedy is shown in 1963 saying that Vietnam could not be won. but if the U. S. pulled out, he might lose the next year’s election. Unfortunately, that was not leadership. It was a calculation that cost many lives. The same risk exists now.

Korea and Vietnam are not identical. But Vietnam raised a relevant question. Can we do it better this time?

Immigration: Budweiser, Eisenhower and Trump with something in common

Have you seen a recent Budweiser commercial in which Eberhard Anheuser meets Augustus Busch and they start a beer company in St. Louis? In fact, Busch was Anheuser’s son-in-law and would eventually take over Anheuser’s brewery.

The commercial implies they spoke English to one another, but they almost certainly spoke German, using their native language like many immigrants. German newcomers faced discrimination because their language and culture differed from American ways.

As their brewery was growing, another family of German origin settled in neighboring Kansas. One of their sons was Dwight Eisenhower, who would lead U.S. forces against Nazi Germany in World War II.

Eisenhower would also become president of his family’s adopted country, as would another descendant of German immigrants, Donald Trump.

Though not subject to direct persecution, these families had all left western Germany to escape political domination by the militaristic Prussians. Beyond the freedom promised by America, they also sought economic opportunity. They succeeded, but only after years of hard work and overcoming discrimination.

These families arrived in the U.S., which imposed few limits on immigration. The country’s population grew rapidly, taking the booming economy with it. Later, limits would be placed on immigration. Chinese were totally blocked until the 1940s.

Quebecois came to work in Maine for similar reasons. Now, Paul LePage, whose first language was French, is governor of the state.

The profile of the four German families is remarkably like the characteristics of people now leaving their old countries behind to come to America. Most seek to escape depressed and dangerous conditions for life in a country in which freedom and economic opportunity are part of its DNA.

Like those families, today’s immigrants face resistance. They may work hard. They may obey the law even more than other residents. But they look different and sound different. That’s enough for them to be kept out or thrown out.

The issue today is the DACA program for people who were brought to the U.S. illegally as young children by their parents. They know no other country and they probably neither look nor sound different from many others in the U.S. Technically, though, they can be deported.

Some, who insist on protecting a majority, white European ethnic base, want them removed simply because they don’t qualify. They believe Trump promised them that all illegal immigrants would be ousted. They would be furious if he did not scrupulously keep his promise – right down to the last child.

Others, possibly including the president himself, have sympathy for the situation of a young person, whose only connection is to the U.S. It is not difficult to imagine how challenging, if not threatening, it would be to be uprooted and sent back the country of your ancestors.

U.S. Attorney-General Jeff Sessions has long made clear his opposition to immigrants. He says that they take jobs away from Americans.

Immigration has increased and created new jobs for the obvious reason that, in a consumer-driven economy, immigrants are new consumers. Sessions cannot provide any data to support his position, especially difficult in a country with today’s low unemployment.

Trump, who launched his presidential campaign on an anti-immigrant theme, seems to believe illegal immigrants turn out to be terrorists or criminals. If you break the law to get into the U.S., it makes sense you are likely to break the law again as a resident.

Both Sessions and Trump may sound logical, but their positions are not supported by the facts. People come to the U.S. because they want the benefits of the system, not to destroy it. To become citizens they must learn about the country – history, we assume without certainty, the rest of us already know.

Trump says the DACA situation demands congressional action. Similarly, being realistic and practical on immigration means that the government cannot and will not eject millions of people contributing to the economy. It must find a reasonable and constructive solution.

Reality dictates that more effective measures must be taken to recover control of immigration by blocking illegal entries. But it also dictates that the country deal with people already within its borders who are working, studying and contributing.

These people have always been included in the U.S. census. From the first census in 1790, the Constitution has required counting “persons” resident in the country – legal and illegal immigrants as well as citizens, to set the number of seats each state receives in the House of Representatives.

Immigration reform should mean becoming at least as realistic as the Constitution itself.

National debt to climb whoever wins budget-tax debate

Congress won't ever block an increase in the debt ceiling. Threats to cap it are pure political grandstanding.

Congress spends money without raising enough tax revenues to cover spending. The shortfall must be met by borrowing. If the debt ceiling increase were blocked, borrowing would be prevented. The U.S. government wouldn’t have the funds needed to operate.

If the federal government could not pay its bills, it would default on its debt. Overnight, the dollar would lose its standing as the principal world currency. No longer the home of the world's standard, the U.S. would forfeit leadership. No amount of military might could make up for that setback.

Opponents of raising the lid on the federal debt want the government cut back even if that means stopping Congress from paying its bills. That won't happen.

The debt ceiling could be made automatic or completely abandoned, because it stands in the way of Congress meeting financial obligations it has approved. Some scholars believe the Constitution guarantees payment on the federal debt, so no ceiling bill is required.

The debt service issue is closely linked to tax reform and the size of the federal budget, the main agenda items before Congress in coming months. President Trump may propose reductions for almost all taxpayers, though tax treatment of the wealthiest remains uncertain. Meanwhile, a small part of the budget, only one-sixth of the total, would bear deep cuts.

The underlying issue will be the size and scope of the federal government, brought into sharper focus than it has for many years. New debt will inevitably be created no matter how tight fisted Congress may be, though optimistic budget projections could include a path toward a balanced budget.

Tax cuts would be applied quickly, before next year’s elections. Government budget reductions need to be phased in, so they would take longer. The result? Even if the Trump proposals were adopted, the federal debt would keep on growing.

Trump economists argue that the tax cuts will stimulate economic growth, eventually yielding more tax revenues. Though the federal debt will increase at first, it should come down over a decade, they say.

The Democrats can be expected to argue in favor of keeping most government programs and for a tax increase on the wealthiest slice of the population. They believe that people who benefit from government policies would oppose program cuts and support such a tax increase.

The GOP’s view is that, above all, people want tax reduction. It remains to be seen how the results of the two approaches would compare.

This debate will take place without any in-depth look at the budget itself. Republicans dislike welfare and environmental programs enacted by Democrats and will target them. They will support increases in military spending. The Democrats will defend most existing programs.

Two-thirds of the budget is devoted to meeting the obligations under Medicare, Medicaid and Social Security. Congress requires payments be made to people who meet eligibility requirements, called “entitlements,” because the recipients have a legislated right to the payments.

They are financed in part by payroll taxes, not income taxes. But the payroll tax revenues do not cover the full cost. Besides, Congress has used some of the payroll tax revenues for other expenses. Shortfalls loom in these programs.

The budget will probably do nothing about entitlements, so their financing problems will grow. So will the debt. Congress will continue to allow taxpayers to live in a dream world of public spending, which will become a nightmare for later generations.

Solutions have been proposed to deal with the budget problems. For Social Security, a wide range of measures that includes increasing payroll tax revenues and slowing the growth in outlays have been proposed. Medicare costs can be cut by better controls. Medicaid eligibility needs review and greater uniformity.

What about the debt? Long-term capital spending for facilities that will used for decades could be financed by long-term debt. But borrowing would not be used to meet current spending except in case of unexpected emergencies like recent hurricanes.

Annual spending should be covered by annual revenues. They both should be kept under continuing review and regular alignment. That means no spending without matching revenues. Zero-based budgeting, in which, from scratch, each activity would be subject to regular justification, could be used.

Unless Washington stops playing politics with tax cuts and by ignoring major budget issues, the debt can only grow worse.

But nothing much will happen this time around. Most likely, despite all the talk, we’ll just keep increasing the debt – and the debt limit.

Ken Burns’ series on Vietnam shows the war that divided America

We are about to start talking about the Vietnam War again. Not because of events in Korea, another divided Asian country, but because filmmaker Ken Burns has produced a major series of programs on that historically divisive conflict.

Many Americans are unfamiliar with this war, though its effects continue to be felt in our public affairs. It teaches lessons for a society now even more divided than during the Vietnam era.

The North Vietnamese Communist government sought to take over the southern half of the country. Even though its leaders had adopted the Declaration of Independence as their own credo, the U.S. worried about this regime’s expansion and its possible “domino effect” across southeast Asia.

Finally, in the Gulf of Tonkin, North Vietnam was reported to have attacked two U.S. destroyers. Those claims brought public and congressional support for America’s military involvement at the eventual cost of more than 58,000 lives of U.S. service personnel. The reports were dubious in one case and fictitious in the other.

The side the U.S. inevitably backed was hardly a democratic model compared with the North. It faced internal rebellion. Corrupt and authoritarian, it was replaced with U.S. support by a military regime. The former president was killed.

Within South Vietnam, there were democratic elements, opposed by both the North and the corrupt regime. In 1971, I accompanied Sen. George McGovern to Saigon (now Ho Chi Minh City) where we met with some of their leaders.

The South Vietnamese opposition complained they were treated almost as if they were the enemy. As we met them in a church building, we came under armed attack by pro-government forces.

Eventually, the North prevailed, and American forces withdrew. In the aftermath, relations between the U.S. and a unified Vietnam have improved, and commerce flourishes. The much dreaded takeover produced a reasonably benign outcome. It hardly had been worth the direct cost, both human and material.

The cost to the U.S. was far greater that the direct losses. The Vietnam War marked a turning point in America’s standing in the world.

Before Vietnam, the U.S. had been seen not only as the most powerful nation but also as a special country progressing toward the best human ideals. It had come to the aid of Europe in two World Wars. It had generously helped rebuild countries that had been its allies and enemies.

While there were serious flaws in this image, the prevailing view was of the U.S. as actively pursuing high political and social ideals. It was not only great, but good.

Involvement in Vietnam aroused controversy in the U.S. and opposition in many countries that had looked to the U.S. for both protection and moral leadership. America strayed from what was seen as its essential character and lost influence. Now, it was respected more for its power than its ideals.

Americans had felt superior to European cynicism. Vietnam turned the U.S. into a country that would now be viewed in a similar light. America would never be the same.

One major legacy of Vietnam, as Burns suggests, was the creation of a deep divide among the people.

Supporters of the war wanted to defeat what they saw as a Communist threat and believed the U.S. would prevail if it made an all-out commitment to the war effort. Once the U.S. became involved, national pride was engaged. Needless killing and uncertain victory were necessary risks.

Opponents focused on the futility of the war and the cruel loss of life by Americans and Vietnamese. Sometimes, they would romanticize the North and its Viet Cong army. They organized frequent demonstration in hopes of convincing the government to halt the increasingly unpopular war.

The division between the two sides was bitter and deep. There was no common ground, leading to a sense of mistrust previously seen only in the conflict over slavery. Opponents on either side were regarded as unpatriotic or hostile to traditional values.

Once this split developed, it made domestic ideological warfare a part of American politics. It remains today.

One casualty of the war was President Lyndon Johnson. More than any other president, he had led the country toward ending Jim Crow, the discriminatory legacy of slavery. For that alone, he deserves an honored place in history. But his standing is undercut by his support for increased U.S. involvement in the Vietnam conflict.

Vietnam was an American tragedy, affecting ordinary people in the U.S. and Vietnam. It had a profound impact on this country. Burns’ series is a timely opportunity to relearn its lessons.

Trump, America’s second independent president, shuns both parties

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“Trump is exactly what Republicans are not,” former Missouri GOP Sen. John Danforth wrote recently.

While that may seem extreme, the statement raises a serious issue about Trump’s relationship to the Republicans. “GOP leaders still puzzle over President Trump,” said a Boston Globe headline.

Is Trump a Republican? He looks increasingly like an independent. He attacks Republicans daily, often more fiercely than Democrats.

Trump could be the second independent president in U.S. history. John Tyler, the vice president who took office when the president died just one month after the 1841 inauguration, had been added to the Whig Party ticket for regional balance. The Whigs were the majority in Congress, but they fought with Tyler.

So they tossed Tyler out of the party with the result that he had no party and no domestic policy success. In a 2017 survey of historians, he ranked 39^th out of 43 presidents.

Trump may have become a Republican purely to have a path to national office. Like Tyler, he was once a Democrat. By now, it is evident that he gets along with congressional Republicans no better than Tyler did with his adopted party.

Without strong loyalty to the party whose label they carried, both Tyler and Trump could easily be classified as presidents who were really independents. And both found the American party system made it difficult for an independent to deal with Congress.

So far, Trump is having no more success with Congress than did Tyler, who, like Trump, thought he could succeed by stressing his ultra-conservative principles. Tyler was said to dislike slavery, though he supported it and kept slaves. At best, Trump is equivocal about white supremacists.

Having alienated Congress, Tyler was the first president ever to face an impeachment effort. Without real party support, he risked removal. It’s early, but Trump could face Republican hostility matching his own open disdain for Senate Majority Leader McConnell, House Speaker Ryan and Sen. McCain.

Trump clearly believes that he has a special link with many voters, regardless of his rocky relationship with the GOP. By keeping the support of his “core” voters, he may reason that elected Republicans will have to follow him or risk losing to Trump-backed primary opponents. In effect, he would create his own party.

The media may not emphasize his ties to the “core” to his satisfaction, but his tweets provide a direct line of communication. The adulation of his backers and Fox News’ favorable coverage could be all he needs. He is unfazed by falling poll numbers, probably because he beat the polls in his surprise electoral victory.

Maine has had more experience than other states with independent chief executives. In recent decades, it elected two independent governors. Gov. LePage might also be classified an independent in the Trump pattern.

The two independents, James Longley and Angus King, were both Democrats who believed they would have a better chance of communicating their message and getting on the ballot if they left the party.

Winner with less than a popular majority, Longley was blunt talker, not above name-calling. His term was characterized by conflict. An upset winner frequently hostile to both parties, he chose not to run for re-election.

LePage has won the governorship twice without a popular majority. He shares much of Longley’s approach, confrontational and almost entirely independent of party, though he ran as a Republican. His positions leave little room for compromise. He often echoes Trump.

King was different from the others. He did not attack the parties, adopting some policies favorable to each. He was seen as a modernizing moderate. When he ran for reelection, most Democrats and some Republicans were with him, and he won by a wide margin.

The lesson of these three Maine governors seems to be that an independent’s greatest likelihood of success results from not taking independence to the point of going to war with the parties in the legislative branch.

Trump’s independence stems from having won when nobody, probably including himself, thought he would. As president, he continues to campaign in the belief that what worked to elect him will work in governing. He tries to intimidate congressional Republicans and spurns Democrats.

If Trump is correct in his belief that he represents a new kind of politics, perhaps he could transform American government.

More likely, he will find that an independent president must make an extra effort to work with Congress, not against it, or risk suffering Tyler’s fate. Having dodged impeachment, Tyler was denied nomination for a second term. His successor was a Democrat.