Transitional plans and insurance exchanges II

One day after my last post, the New York Times ran an article on Geisinger Health, an insurance company requesting a large rate increase on the PA exchange. One reason why? Because the transitional plans are keeping considerable numbers of healthy people out of the exchanges. It would have been nice if the article had mentioned it before three paragraphs from the end.

GOP's near-total blockade on Obama's appointments continues -- but you can help a bit

While we were all focused on the primary elections on Tuesday, something interesting happened on the Senate floor when Democrats made a conscious, polite and ultimately futile effort to get a few judges confirmed.

Hawaii Senator Mazie Hirono (D-Hawaii) asked for unanimous consent to vote on Obama's eleven district court nominees that have been approved by the Senate Judiciary Committee -- without objection -- and have been awaiting the action of the full Senate (see the full Senate Calendar here).

Sen. Majority leader Mitch McConnell (R-Kentucky)  objected to the request.

Then Chuck Schumer (D- New York) asked for unanimous consent to vote on the seven that have been approved by Judiciary -- again without opposition -- and have been waiting on the floor since November 5. 

McConnell again objected.

Then Ben Cardin (D - Maryland) said, OK, could we vote on the four that have been  waiting on the floor since  October 29 -- six months ago. Those are

Paula Xinis, District of Maryland,
Brian R. Martinotti, District of New Jersey, 
Robert F. Rossiter, Jr., District of Nebraska,
Edward L. Stanton III, Western District of Tennessee

John Cornyn (R-Texas) objected.

Finally,  Cardin said, could we maybe just vote on the Xinis nomination, since she was approved by Judiciary in September, no one has raised any opposition to her and she has been awaiting floor action for seven months?

Cornyn objected again.

We all know about the near complete refusal of Senate Republicans to even meet with, let alone hold hearings for, vote on or even, gasp, approve President Obama's Supreme Court nominee Merrick Garland. 

But we can't forget about the rest of these nominations either that are facing nearly a complete blockade by Republicans. In addition to the eleven awaiting floor action, 41 nominees are awaiting action in the Judiciary Committee.

In the 2015-2016 Congress to this point, the GOP-controlled Senate has only confirmed two circuit court appointments and fifteen district court judges.

For comparison, in the 2007-2008 Congress through April 30, the Democratic-controlled Senate had confirmed seven of George W. Bush's circuit court nominees and 38 of his district court nominees.

And in 2013-2014, by April 30, the Democratic controlled Senate had confirmed fifteen nominations to the circuit courts and 54 to the district courts.

It's reasonable that the GOP wants to scrutinize Obama's appointments a bit more (and even reject a few),  but these 11 judges have had been scrutinized. They've been waiting for confirmation between seven and 14 months.  They have all cleared a GOP-controlled Judiciary committee by voice vote. There is no opposition -- reasonable or otherwise -- to giving them their commissions. This is only about delay.

These are judges that are uncontroversial and needed to help the government perform their basic functions. Unlike Garland, they don't represent huge ideological stakes in themselves, so a bit of pressure might get the Republicans to let a few go.

Consider calling your state's Senators, especially if they are Republicans -- and especially if you're from Texas and have Cornyn as your Senator. (Don't e-mail, that's useless). Here's a list of numbers for their Washington offices. State your name, and give  a brief, polite (don't be a jerk) message asking them to hold a vote on the 11 district court nominees that await floor action.

The 11, including their numbers on the executive calendar are:

#307 Paula Xinis, District of Maryland,
#357 Brian R. Martinotti, District of New Jersey, 
#358 Robert F. Rossiter, Jr., District of Nebraska,
#359 Edward L. Stanton III, Western District of Tennessee
#362 Julien Xavier Neals, District of New Jersey
#363 Gary Richard Brown, Eastern District of New York
#364 Mark A. Young, Central District of California
#459 Marilyn Jean Horan, Western District of Pennsylvania,
#460 Susan Paradise Baxter, Western District of Pennsylvania,
#461 Mary S. McElroy, District of Rhode Island
#508 Clare E. Connors, District of Hawaii

Labor's prospects over the next several years look alarming

As another election year dawns, I find myself contemplating the future of the labor movement.

The immediate future looks grim.

That isn't to say that the labor movement is going to die, or that unions won't continue to play a role or help working people. And it certainly doesn't mean that activists should stop fighting for the rights of working people everywhere.

However,  it's much more likely than not that the labor movement is going to suffer some serious hammer blows in 2016 and the remaining years of the decade.

I'll focus narrowly in this post on the spread of (so-called) Right to Work (for less) laws (RTW).

RTW is an insidious concept that cloaks itself in righteous language to divide workers and drastically weaken the power of their organizations.  By the National Labor Relations Act and the state statutes that govern collective bargaining for state and local public employees, unions have to represent all employees in a bargaining unit.  In 25 states, the union has the ability to bargain to charge fair-share fees of all member of the unit, which represent the costs of collective bargaining.  Full dues, which represent political activities engaged in by the union, are only paid by individuals who want to be members who in turn have rights to vote and participate in the governance of the union.

In an aside, remember that in order to represent workers, unions have to win an election to become the bargaining agent, and they are controlled by the members through democratically elected officers. Finally, they can be decertified if a majority of workers vote in an election to remove or replace the union. This is a fact glossed by anti-worker forces.

What RTW laws do is allow workers to free ride of the union's efforts by banning fair share fees. The corporate-backed groups and think tanks pushing RTW argue that workers have a right to not join a union (though they are rather silent on a worker's right to join a union). Of course, though banning fair-share fees, RTW laws still compel a union to represent any one in a bargaining unit. As a result, we create a free-rider problem described by Mancur Olson: why should you pay for something you can get for free?

RTW is insidious because it only appears to cripple a small part of collective bargaining rights: in itself, it doesn't touch the ability to bargain for better wages or working conditions. But by undermining the union finances, it cripples the ability of a union to organize, bargain and protect strong contracts, which can lead to fewer members, which leads to further financial erosion. At worst, a death spiral happens, leaving a bunch of isolated, cynical workers in its wake -- who then can be easily exploited by unfettered bosses.

Currently 25 states have RTW laws, and 25 do not. Since 2011, when Scott Walker eviscerated public sector unions in Wisconsin, three states have jumped on the RTW bandwagon: Indiana, Wisconsin and Michigan.  From a worker's perspective this should be alarming, because all three of these states are in the industrial Midwest, which traditionally has a strong union presence. Michigan was the birthplace of the United Auto Workers (UAW), whereas the Association of State, County and Municipal Employees (ASCME) originally formed in Wisconsin.

As the parties have polarized and the remaining labor-friendly Republicans retire or are overwhelmed by their conservative colleagues, this momentum is likely to continue.

Extreme Risk:

West Virginia: I suspect it's pretty much all over in West Virginia. Like many Appalachian states over the last several election cycles, the legislature has become sharply more conservative, with the GOP breaking the dam in the 2014 elections. A RTW bill was shelved in 2015, but with GOP gains likely in both houses of the legislature and a Republican taking over the governor's chair very likely in 2016, in 2017, RTW's arrival will be a given.

Kentucky:  A slimmer and slimmer Democratic majority in the state House of Representatives is the only thing standing between RTW and Kentucky. The extreme conservative Matt Bevin's win as governor jumps this state from medium risk to extreme risk, as anti-labor policies are core to Bevin's identity -- in two of his first executive orders, he discarded higher minimum wage requirements for state agencies and issued a hiring freeze in filling unstaffed positions.

The Democrats may hang on to their house majority in 2016, since they were somehow able to cling to it in the low-turnout year of 2014.  However, the off-year election of 2018 is another animal entirely.

Several Kentucky counties have already tried to issue RTW laws on their own; these efforts are currently tied up in court, but the winds are very much blowing the wrong way for labor rights in this state.

High Risk:

Missouri:  Democratic Governor Jay Nixon vetoed a RTW bill in 2015 and the Democrats backed by a few nervous Republicans have managed to sustain those vetoes in the legislature, despite the GOP maintaining a supermajority in both chambers. Unlike West Virginia, the Democrats have a fighting chance in the governor's race in 2016, despite Missouri drifting further into the GOP orbit over the last decade. With a Democratic win in the governor's race, Missouri is likely safe for another four to eight years. With a GOP victory, RTW would likely be the very first thing on the government's agenda in 2017.

Medium Risk:

Ohio: With Republicans in strong command of both houses of the state legislature and the governorship for the foreseeable future and likely maintaining the governorship, Ohio would seem to be a likely candidate for a RTW bill -- and one is currently percolating in the legislature.

However, Ohio Republicans have a bitter memory of the last time they tried to push a major anti-worker bill through the legislature holding them back. In 2011,  Ohio Republicans pushed a Wisconsin-style bill designed to strip most collective bargaining rights from public employees. The bill passed, but  Labor and progressive groups gathered more than a million signatures to force a referendum, in which 62 percent of voters rejected the bill. 

That memory may be holding the GOP in check for now, but if other states continue to push through anti-labor laws, Ohio Republicans will likely eventually press forward.

Possible risk

Montana:  Montana's state legislature has been in solidly Republican hands since 2010, but Democrats have held the governor's chair. Incumbent Steve Bullock is in a reasonably strong position for the blue team, so hanging on to labor rights for at least four more years appears possible in this traditional mining state.

New Mexico: New Mexico currently has Democrats in control of the State Senate, but lost control of the House of Representatives in 2014.  Presidential year turnout will help protect the Democratic senate advantage in 2016 and perhaps help them retake the house.  But if Democratic power in the legislature erodes further, anti-labor legislation will be on the agenda when a Republican is governor.

New Hampshire and Pennsylvania might also be at risk. The Granite state occasionally gets massive GOP majorities in the two houses of its legislature, as it did after 2010. In that case a few moderate Republicans helped the Democrats in the house sustain Democratic governor John Lynch's veto of a RTW bill in the 2011-12 session. As long as the Democrats hold the governor's chair, they should be OK here, but elections are close and there is an open seat in 2016.  Pennsylvania is safe as long as Democrat Tom Wolf, elected in 2014 is in office, but the GOP has a built-in advantage in the state house and its majorities are becoming dominated more and more by extremely conservative ideologues.  Protecting Wolf in 2018 and drawing better districts in 2020 will be key to keeping the Keystone state working people from getting their collective bargaining rights curtailed.

The Supreme Court

This list doesn't count the worst probable hammer blow that's going to fall on labor this year. That would be Friedrichs vs. The California Teacher's Association, which has made its way to the Supreme Court a case set for oral arguments on January 11. The case will likely result in a 5-4 decision -- authored by Sam Alito--  overturning nearly four decades of precedent and invalidating fair share fees for all public sector unions on the specious grounds that collective bargaining with the government is a form lobbying (political speech), which cannot be compelled. Of  course, the union will continue to have to represent the interests of all of its members without their financial support, but I guess speech rights for dues payers aren't as important.

I so do weary of Alito's conception of Freedom of Speech in which it becomes much easier for wealthy owners to speak (see Citizens United) and much more difficult for working class people to organize so they can speak.

Again, we shouldn't despair from the likely reverses that are coming. The movement goes on and labor will continue that struggle. However, we should be aware that the struggle is likely going to become more difficult, though if we can win a few important elections -- we can blunt some of the blows.

And remember, that the only way to overcome RTW both legislatively and on the ground is to organize.

Solidarity.

Expanding the Umbrella: Medicaid Expansion 2015 Review and New Year's Preview

With 2016 right around the corner, and several new governors moving into office, it's as good of time as any to take stock of where the Medicaid expansion has gone and the prospects for progress in the new year.  Despite massive Democratic setbacks at the state level in the 2014 midterm elections, Medicaid expansion fared reasonably well in 2015, and 2016 posts several opportunities for new states to expand as well, as well as one at risk of backsliding.

First, we visit the ghosts of Medicaid expansion past:

As Chart I shows,  the ACA Medicaid expansion has proceeded at a similar overall pace to the original Medicaid take-up in the late 1960s, though the holdouts to Obamacare are likely to offer stiffer resistance than the late adopters of the initial program.

Democratic defeats in the 2014 elections likely prevented expansions in Maine and possibly Florida, and may have influenced resistance to expansion plans in several other states, including Tennessee, Utah and Wyoming. However, Four new states joined the expansion -- Indiana, Pennsylvania, Alaska, and Montana -- which increases the number of states fully expanding Medicaid from 26 to 30. 

Head below the fold for state-by-state analysis and a peak at 2016.

Medicaid Expansion Keeps Stumbling Forward -- and Proves Surprisingly Resilient

With the results of the 2014 elections, the pace of Medicaid expansion has become frustratingly slow for progressives.  However, the overall picture has two very important positive points for those seeking to provide universal health care in this country. First, despite meeting several setbacks and roadblocks recently, the expansion continues to grind ahead –excruciatingly slowly, but ahead all the same -- to new states. Second, recent developments in Arizona and Arkansas suggest that a state’s expansion may be durable even in states that get taken over by hard-right governments.

On the first point, Indiana joined the parade of Conservative states expanding Medicaid under a waiver in January. Pennsylvania, under its new Democratic Governor Tom Wolfe, has thrown out the complicated waiver plan submitted by outgoing governor Tom Corbett and is replacing it with a traditional expansion more congenial to beneficiaries (elections matter). Frustrating setbacks have happened in Tennessee and Wyoming, when legislative committees defeated plans negotiated by their governors to expand Medicaid, at the behest of an Americans for Prosperity pressure campaign. However, Utah and Montana are still considering their own plans – and Kansas(!) of all places looks like it may join soon too. Vox, as usual, has the snappy summary.

The second point is more interesting and, for now, just as encouraging. In 2013, Arkansas had negotiated an expansion with waivers under Democratic Governor Mike Beebe to mollify the Republican-controlled legislature. However, it looked like the plan might not survive new Republican Governor Asa Hutchinson and a much larger and more conservative Republican majority elected in 2014. But Hutchinson got behind the program with a few tweaks and convinced the legislature to approve it for another two years while forming a committee to seek a new waiver in 2017.   

In Arizona, the situation appears more ambivalent. Outgoing Republican governor Jan Brewer choose to expand Medicaid in 2012 over howls of protest from conservatives in her legislature. Incoming Governor Doug Ducey has suggested he’s against the expansion, while conservatives made gains in the Arizona statehouse in 2014. Medicaid expansion looked doomed.

But an in-depth examination of legislation Ducey just signed trying to curtail the expansion is instructive. The legislation consists of two Republican pet rocks: attaching work requirements to Medicaid recipients, and limiting beneficiaries to five years total of receiving Medicaid before throwing them off the program. It’s an ugly bill. But notice that the law doesn’t eliminate the expansion, it only attempts to modify it with issues a GOP legislator could plausibly defend as “common-sense reforms.”More importantly, any of these changes would have to be negotiated with the Federal Department of Health and Human Services.

At least for the next two years, those negotiations are going to go like this:

ARIZONA: “We want you to give us a waiver to create work requirements for beneficiaries and throw them out of Medicaid after five years” (hands over proposal).

HHS SECRETARY BURWELL: “Would it annoy you if I did this?” (Folds proposal into paper airplane and tosses it back at Arizona’s forehead)

The bill binds Arizona state officials to go back to the Feds every year and beg for the waiver.  Those conversations are going to go like this:

ARIZONA: “We want you to give us a Medicaid waiver to…”

BURWELL: (Takes proposal. Blows nose on proposal. Crumples it up and hands it back)

What we have here is Politics 101: it allows Arizona Republicans to both whine loudly about how horrible the federal government is, while looking like they are doing something to fight the dastardly Obamacare Medicaid expansion by writing sternly worded letters. They also get to quietly take advantage of all its benefits (including federal funding) that will remain at least as long as a Democrat controls the White House.

So at first glance, at least, the Medicaid expansion is looking surprisingly resilient, even in its infancy. Despite the poor results of the 2014 elections, the expansion continues to meander forward in several states. And every state that takes the expansion may have quite a hard time getting rid of it. This stickiness is good news for justice and for hundreds of thousands of people who get access to health care.

Obamacare is about People, not States

On January 30, Ezra Klein posted an insightful Vox piece about one of the great ironies of the Affordable Care Act.  After a lot of thought of my own, however, I don’t think it’s much of an irony at all. 

Klein’s analysis noted that the original ACA – supported heavily by Democrats – featured a massive redistribution of wealth from Blue States to Red States.  The people helped by Obamacare’s Medicaid expansion and exchange subsidies were disproportionately concentrated in the states of the ex-Confederacy that had low-wage economies with skimpy existing Medicaid programs. (An old joke in Mississippi claims that you have to be legally dead to qualify).

The irony that Klein points out has been that Republicans are fighting tooth and nail to turn the ACA into a program that drains money from Red states and transfers it to Blue States. When the Supreme Court held that the Medicaid Expansion had to be optional for states, many states dominated by Republicans declined the expansion while Blue States snapped it up, shifting the benefits flow from Red States to Blue States If the Supremes decide the case of King vs. Burwell in favor of the forces of darkness, it will declare subsidies on exchange marketplaces illegal – but only in the states on the federal exchange, which of course are disproportionately Red States. As a result, higher earners in Texas will be sending their increased Medicare taxes to poor and working-class people in states like New York and California while their own states lose out.

It’s an interesting puzzle, but I think it can be explained quite easily – at least on the liberal side of the equation – by changing our unit of analysis. Klein looks at states, but I think it makes more sense to look at people to explain this paradox. On some issues, perhaps it makes sense to look at issues as state vs. state.  If a major manufacturer decides to leave one state and move to a second, for example then pretty clearly the second state is better off relative to the first. Politicians will act accordingly and line up state against state.  

But the motivating purpose behind the Affordable Care Act wasn’t about New York vs. Texas, it was about 48 million people in the United States who didn’t have health insurance. Ohio Senator Sherrod Brown didn’t refuse to take federal health insurance because Florida got more Medicaid dollars than Ohio, but rather in solidarity with millions of Floridians and Ohioans who didn’t have access to health care at all. If Mississippi took $14.5 billion in federal money over the next decade to expand Medicaid, I wouldn’t be mad that that money wasn’t going to Pennsylvania, my latest state of residence; I’d be celebrating because 169,000 of my fellow citizens got access to health care.

On the flip side, the logic is perhaps more difficult to explain for a Red State GOP governor like Rick Perry or Mississippi’s Phil Bryant. There’s the potential that they just don’t understand it. Perry recently suggested that millions of Texans liked not having insurance, which may represent a weak dodge or actual ignorance of reality. But there’s also the possibility it’s about people for them too – specifically “those people” who are poor and likely have a darker hue of skin and are viewed as undeserving of federal benefits. Politicians used to be able to wrangle earmarks and pork for their state , which reduces the role of ideology, but ideological sorting and polarization has been getting stronger over the last 40 years. As a result, politicians who rely on bringing home federal dollars to get votes find themselves facing tough primaries – like the one Thad Cochran barely survived in Mississippi in 2014.

We can solve Klein’s puzzle then by re-imagining the pieces. It’ not about cash flows to states, it’s about people – and whether a state official’s ideological blinkers permit those without access to health care to be seen as human beings deserving of compassion or dignity.