Wesley Smith has a question about the Republican health care plan:

I am wondering why opponents haven't conceded a big point Speaker Ryan has asserted in defending his three-stage approach: A full repeal would require 60 votes in the Senate because it would be subject to the filibuster…Hence, understanding that the contents of the first phase can be debated, if Obamacare is going to be defanged, doesn't Ryan's three-stage approach make complete sense?

Of course Ryan is right. Everyone should concede that. So why haven't they?

Answer: Because for seven years Republicans have been telling everyone who will listen that if they get into power they'll repeal Obamacare, full stop. They never said "most of it" or "just the parts we can repeal via reconciliation." Just the opposite: They used the most thunderous, uncompromising language possible. Obamacare was a cancer that needed to be fully excised. And they'd do it.

Something on the order of 1 percent of voters understand filibusters and reconciliation, and Republicans were very careful never to mention those things. So that means 99 percent of Republican voters think Obamacare can be fully repealed if only the GOP leadership has the guts to do it. This is now causing problems for Ryan, but he has only himself to blame. He said he'd repeal Obamacare, and now the Republican base wants him to do it. All this yakking about reconciliation and three-phase plans sounds like nothing more than yet another sellout.

Megan McArdle is no fan of Obamacare, but she understands what will happen if Republicans demolish it without putting anything of substance in its place:

The base may rejoice when they hear that Obamacare has been "repealed" (sort of). But their cries of glee will be drowned out by their wailing when they find that they cannot buy individual insurance at all.

That's why I don't understand what Republicans are trying to do with this bill. What do they think will happen after they proudly proclaim that they've repealed Obamacare—followed in short order by the complete implosion of the individual market? Do they really imagine that they will be allowed to leave the rubble-filled lot there and proclaim that they've undone President Obama's mistake? Or that, having watched them destroy the individual market, voters will be eager to let Republicans touch any of the other structures cluttering up America's health-care policy landscape?

I am puzzled by this. As you all know, I agree entirely with McArdle. If you keep the regulations on preexisting conditions—and Republicans have no choice about that—but cripple both the individual mandate and the subsidies, the result is catastrophe. What happens is simple:

  1. Young, healthy people leave the market because they're no longer required to get insurance.
  2. Poor people of good or average health leave the market because they can't afford coverage with only skimpy subsidies.
  3. Even if they have to beg, borrow, or scrimp, sick people will all sign up and insurance companies will be forced to accept them.
  4. With a pool full of expensive, sick people, and not much of anyone else, insurers will lose massive amounts of money.

This is no secret. It's obvious to everyone. And yet, I hear very few people talking about it. Why? Shouldn't insurance companies be yelling at the tops of their lungs? If the Republican bill passes, they'll have only two choices: lose lots of money or abandon the individual market altogether. I'm guessing the latter. Legally, the only way they can avoid having to insure the very sick is to simply stop selling individual coverage. Hell, a public company would probably be opening itself up to lawsuits for breach of fiduciary duty if it didn't abandon the market.

Am I missing something here? Why isn't this the biggest thing people are talking about? Why isn't it on cable news 24/7? Why aren't insurance companies screaming bloody murder? Why is this destruction of the individual market getting so little attention?

UPDATE: Paul Ryan is on TV suggesting that not only is this not a problem, but his bill will make things better. People with preexisting conditions will all be covered by high-risk pools, while everyone else will buy ordinary insurance. This is ridiculous. First, the funding for the high-risk pools is far too small to cover everyone who would need it. Second, how do you force people to use high-risk pools? You can't. Sick people can legally buy from anyone who sells coverage, and they will.

With that taken care of, now Ryan is trying to pretend that advanceable tax credits are different from Obamacare subsidies. What a hack.

DHS Secretary John Kelly announced yesterday that illegal border crossings have plummeted in the past few months:

From January to February, the flow of illegal border crossings as measured by apprehensions and the prevention of inadmissible persons at our southern border dropped by 40 percent. The drop in apprehensions shows a marked change in trends. Since the Administration’s implementation of Executive Orders to enforce immigration laws, apprehensions and inadmissible activity is trending toward the lowest monthly total in at least the last five years.

....This is encouraging news as in the period from Oct 1, 2016 to the Presidential inauguration, U.S. Customs and Border Protection reported 157,000 apprehensions of illegal immigrants — a 35 percent increase over the previous fiscal year, with family units increasing by more than 100 percent. However, since President Trump took office on January 20, we have seen a dramatic drop in numbers.

That's a remarkably partisan statement, but perhaps it's not all that out of the ordinary? In any case, here's a more readable chart than the one CBP provides:

Most of President Trump's routine boasting is groundless, but this is one case where I think he really has had an effect. His policy changes haven't had much impact yet, but the mere fact of his boasting, and of CBP's highly publicized raids, has probably scared a lot of potential border crossers away. This is a case where fear works.

But will it work for long? The problem with amping up the bluster is that eventually it becomes the new normal and no longer has much effect. By that time, you really need to have an effective policy in place, and it's not yet clear if Trump has the attention span or political skills to make that happen. We'll see.

Here are a few miscellaneous things from my afternoon trawl of the news:

Thing the first:

Kansas Gov. Sam Brownback is in talks with President Donald Trump’s administration about taking an ambassadorship position, according to sources close to the governor. No offer has been extended yet, according to The Star’s sources, but the governor has discussed the possibility of taking a position as the U.S. ambassador to the United Nations for food and agriculture, a position that would move the Midwestern governor to Rome.

The ambassador for what? There are two takeaways from this: (a) Trump really doesn't want Brownback in his administration, and (b) Brownback really wants to get out of Kansas. His tenure as governor has been a nonstop trainwreck, highlighted by his huge tax cuts for the rich that have tanked the state's economy. There's really no way to fix things without raising taxes, so Brownback just wants to hightail it out of the governor's mansion and leave the problem to somebody else. And hey, Rome is a nice place for an exile.

Thing the second:

Check out this picture of Trump holding a conference in the Oval Office:

Trump is apparently so insecure that he holds every conference from behind his desk, even when it involves seven people. Who does that? In all the pictures I've seen before of presidents, they're out from behind the desk sitting on a chair or a sofa on equal terms with everyone else. But Trump seems to need the desk to remind himself that he's in charge.

Thing the third:

This is just a bit of a ramble that's on my mind. I've been trying to figure out how to respond to the Republican health care plan, but nothing seems quite right. I've written plenty about the details, and so have others, but none of this really gets the true story across.

Here's the thing: anyone with even a cursory knowledge of health care knows that the Republican plan isn't serious. Paul Ryan knows it. Mitch McConnell knows it. Mike Pence knows it. Mick Mulvaney knows it. Everyone knows it. It's just a cynical joke. It will cover virtually no one, and will quite possibly destroy the individual insurance market in the process. Its only purpose is to repeal about $600 billion in taxes on the rich.

This is not really controversial or even very partisan. The plan just doesn't do much of anything for anybody except the rich. But we're all expected to stroke our chins and pretend that it's a serious proposal that should be seriously analyzed. There's something badly wrong about this. Why do we all have to do this?

Friday is jobs day, when the BLS announces how many new jobs were created in February. One of two things will happen:

  • The number will be mediocre, in which case Trump will say we're still living with Obama's job-killing regulations, but don't worry, he's going to take care of that soon. MAGA!
  • The number will be high, in which case Trump will say that in his first month he's already gotten the economy moving again and there's more to come. MAGA!

No matter what happens, Trump is a winner.

UPDATE: Text and headline changed to account for the fact that apparently today isn't Thursday. Sigh.

Over at 538, David Wasserman has an interesting piece about the growing partisan divide in America. In particular, there are hardly any purple counties left:

Of the nation’s 3,113 counties (or county equivalents), just 303 were decided by single-digit margins — less than 10 percent. In contrast, 1,096 counties fit that description in 1992, even though that election featured a wider national spread. During the same period, the number of extreme landslide counties — those decided by margins exceeding 50 percentage points — exploded from 93 to 1,196, or over a third of the nation’s counties.

But things are actually even more interesting than Wasserman suggests. He illustrates the growing partisan trend with a set of maps from 1992 to 2016, which show the increasing number of landslide counties. But it turns out there's very little change from election to election. In fact, there are only two elections since 1992 which produced a big change:

In years when a Republican is elected, the nation becomes far more polarized. Or, if you prefer, in years when the nation becomes far more polarized, a Republican wins the election. Discuss.

My apologies. I said earlier this morning that Donald Trump's only comment about the Republican health care bill had been a single ambiguous tweet. But it turns out he also said this:

This will be a plan where you can choose your doctor, and this will be a plan where you can choose your plan. And you know what the plan is. This is the plan. It’s a complicated process, but actually it’s very simple, it’s called good health care.

OK then.

Christopher Ingraham asks, "Is the money we're spending on health care keeping us alive?" It's this chart that gives him pause:

This is a dramatic chart, for sure. But I'm not sure it highlights the right issue. The US spends a lot more on health care than other countries, but that's not because we provide better or worse health care. We just pay more for the same stuff. We pay doctors more and we pay nurses more. We pay more for drugs, more for hospital stays, and more for tests. This is a consequence of a mostly private health care system that doesn't control costs very well, but it says nothing about the quality of care.

Instead, I would draw your attention to this chart:

The difference in life expectancy between the top and bottom is ten years for women and a stunning 15 years for men. Nor do you need to look at the very top to match European life expectancies. A merely average American has a life expectancy of 82 years, right in line with other advanced countries.

So here's the question: I assume that every country shows a decline in life expectancy as you get poorer. But do other countries show the astonishing decline we have in the US? I can't find an authoritative analysis of this, but I scanned through some reports from different countries and it looks to me like the income difference in most places is half to two-thirds of the US difference.

This is where I suspect our health care system goes awry: in quality of care to the poor. Compared to other advanced countries, it's terrible, and that shows up in the life expectancy numbers for the poor.

This is testable with the right statistics. In particular, I'd be interested in seeing the chart at the top not for overall life expectancy, but for life expectancy of those with median incomes. Does any such thing exist?

The American Medical Association has decided to speak up after all. They are not happy with the Republican health care plan:

While we agree that there are problems with the ACA that must be addressed, we cannot support the AHCA as drafted because of the expected decline in health insurance coverage and the potential harm it would cause to vulnerable patient populations.

....It is important that the amount of credits available to individuals be sufficient to enable one to afford quality coverage. We believe that credits should be inversely related to an individual’s income....We are concerned [] with the proposed rollback of the Medicaid expansion under the ACA....The AMA cannot support provisions that repeal the Prevention and Public Health Fund or that eliminate the ability of patients to receive their care from qualified providers of their choice.

....We encourage you to ensure that low and moderate income Americans will be able to secure affordable and adequate coverage and that Medicaid, CHIP, and other safety net programs are maintained and adequately funded. And critically, we urge you to do all that is possible to ensure that those who are currently covered do not become uninsured.

Other than that, Mrs. Lincoln, how did you like the show?

In a separate commentary, under the headline "Physicians reject House ACA replacement bill," the AMA's president says this: "The ratings and analytics firm S&P Global Ratings has already estimated that as many as 10 million Americans could lose coverage if this bill becomes law....That just won’t do."

Among the big industry players, only the insurance companies continue to remain quiet about the Republican plan. However, with everyone else opposed to it, they might finally decide to speak up. They're the ones for whom RepubliCare is an existential threat, after all.

But while we're on the subject, has anyone noticed that there's one other player who doesn't support the Republican bill? So far, President Trump's sole comment about it has been this: "Our wonderful new Healthcare Bill is now out for review and negotiation." By Trump standards, that's practically a denunciation. Elsewhere in the administration, Tom Price apparently hasn't read the bill and Sean Spicer's big pitch was the fact that it has fewer words than Obamacare. This is a decidedly restrained approach. It appears that Trump doesn't want to be too closely identified with this dumpster fire of a bill. He may not be very smart, but he has an animal cunning that's probably warning him to keep his distance.

Engagement Labs is a company that tracks "what people are talking about." Brad Fay, one of their executives, tells us that during the presidential campaign people were talking very negatively about everyone. They were more negative about Donald Trump, but they were plenty negative about Hillary Clinton too. However, the gap between the candidates changed from time to time based on external events:

Most decisively, there was a sudden change in the net sentiment results that followed immediately after FBI Director James Comey released his Oct. 28 letter to Congress about a renewed investigation of Clinton emails. Immediately afterwards, there was a 17-point drop in net sentiment for Clinton, and an 11-point rise for Trump, enough for the two candidates to switch places in the rankings, with Clinton in more negative territory than Trump. At a time when opinion polling showed perhaps a 2-point decline in the margin for Clinton, this conversation data suggests a 28-point change in the word of mouth "standings." The change in word of mouth favorability metric was stunning, and much greater than the traditional opinion polling revealed.

Of course, a picture is worth a thousand words:

In late October, Clinton leads Trump by 24 points in the Engagement Labs survey. Two days after the Comey letter is released, Trump is ahead by 4 points. Trump kept that lead until Election Day.

Once again: Clinton did nothing particularly wrong in her campaign. She didn't ignore working-class whites. She wasn't too cautious on policy. She didn't overestimate the impact of educated voters. She wasn't complacent. What happened was simple: 12 days before the election, the FBI director released a letter saying he had found a brand-new trove of emails and implying that this might finally be the smoking gun about her private email server. That's it.

We'll never know for sure if James Comey did this because he's terminally stupid and didn't realize what impact it would have, or if he did it knowing full well what impact it would have. But he did it. And that's why Donald Trump is president.