Republicans like to say they want to "reform" Medicaid because it's so terrible for poor people. "More and more doctors just don’t take Medicaid," Paul Ryan claimed when he unveiled his health care bill. Jordan Weissmann isn't buying it:

It is true that many doctors do not accept new Medicaid patients, in large part because the program pays physicians relatively little for their services. But new data suggests Ryan is dead wrong when he says this is a growing problem. If anything, it appears that more doctors have started to see Medicaid enrollees in the years since the program expanded under the Affordable Care Act....According to the doctor job placement company Merritt Hawkins, 53 percent of physicians in 15 large cities said they were accepting Medicaid patients in 2017. That's up from 45.7 percent in 2014, when the Medicaid expansion began, and down slightly from 2009, when it was 55 percent.

This is all true, but it's worth taking a look at the whole picture. Here's the Merritt Hawkins data since 2004 for Medicaid and since 2014 for Medicare:

Among specialties, the number of doctors taking new Medicaid patients has stayed about the same since 2004. However, in family medicine, it's gone down by about ten points. And in both cases, the numbers hover around 55 percent, far lower than Medicare's 80 percent.

It's also worth taking a look at the enormous differences from city to city:

This chart is for big cities. Average acceptance rates are slightly higher in mid-size cities, and the distribution between cities is a little narrower. Overall, Medicaid is a little better off in mid-size cities and towns than it is in big urban areas.

Generally speaking, Weissmann is right that doctor acceptance of Medicaid doesn't appear to be a worsening problem. He's also right about Republican crocodile tears: if they want to improve acceptance rates, they need to pay doctors more, not cut funding for Medicaid under the guise of reform. And he's right that Medicaid isn't too different from cheap private plans that significantly restrict doctor choice.

At the same time, Medicaid definitely has its problems. Only about half of doctors accept it, and what's worse, this varies dramatically between cities. If you live in Minneapolis or Philadelphia, you're probably OK. But if you live in New York or anywhere in the South, good luck finding a doctor who's nearby and doesn't have huge wait times.

We accept this as a nation because, hey, it's just welfare for poor people and they should be grateful for what we give them. And for the most part, they are: people on Medicaid generally give it good marks because it's simple, free, and way better than not having any coverage at all. But the way we treat it is still pretty shameful. The day can't come soon enough when Medicaid, Medicare, and private coverage are finally all merged into a single national system and everyone is guaranteed decent care.

Apparently the House leadership is going to introduce an amendment to its health care bill tonight. According to Politico, here are its major provisions:

  • Adds $75 billion to reduce premiums for old people. But in an awesome display of legislative farce, the amendment doesn't actually set up the tax credits. It just tells the Senate to do it. So House Republicans have to vote for a pig in a poke.
  • Repeals Obamacare taxes a year earlier.
  • Increases Medicaid reimbursements for the elderly and disabled.
  • Deletes a provision that allows people to transfer unused tax credits into a Health Savings Account. Apparently some activists were afraid this might indirectly allow tax credits to be used for abortions.
  • Allows states to establish work requirements for Medicaid.
  • Allows states to take Medicaid as a block grant, presumably so they have more flexibility to use Medicaid money any way they want and more authority to tighten requirements for the poor.

In summary, we have:

  • Two provisions that help the old.
  • Two provisions that screw the poor.
  • Three provisions that increase the deficit.
  • And one provision that somehow caught the attention of anti-abortion paranoids.

If that isn't a Republican amendment, I don't know what is. Sadly, it also spends more money, which is enough for many members of the tea-party wing to oppose it. So we're back to Paul Ryan's usual conundrum: Half of Republicans are worried about his bill being disastrously stingy, and want to spend more money to guarantee higher benefits. The other half are worried that the bill continues to spend any money at all, and want to cut its already meager benefits further in order to reduce spending even more.

How do you reconcile this? By telling everyone, "This is your one chance to repeal Obamacare." I guess that might do it, though it's hard to say for sure. The vote is coming on Thursday, and plenty of people think Ryan doesn't have the numbers to pass it. We'll see.

Neil Gorsuch is unlikely to give away anything concrete in his confirmation hearings for the Supreme Court, so Ramesh Ponnuru has a list of philosophical concerns for him to address. Here's question #1:

The Supreme Court in its early decades rarely set aside federal laws. It first did so in 1803, and went another 54 years before doing it again. So at least one of the following three things would seem to be true. Either the federal government now enacts a lot more unconstitutional laws; or the justices gained a better understanding of their jobs as the Founding receded into history; or the Court has seized more and more power from the other branches. Which explanation makes the most sense?

I assume that the "correct" answer is the third one, though Ponnuru doesn't give away his own opinion. But this is a very salient question. In 2012, conservatives urged the Supreme Court to set aside Obamacare even though:

  • Everybody agreed that health care was a large and indispensable part of interstate commerce. Everybody also agreed that the Constitution grants supreme and extremely broad authority over interstate commerce to the federal government.
  • Obamacare was unquestionably the kind of political issue that's assigned to Congress and the executive by the Constitution.
  • It was passed properly and signed into law after lengthy deliberation and careful consideration.
  • A string of precedent more than 60 years old suggested Obamacare's provisions were well within Congress's commerce and taxing powers.
  • It required people to take certain actions and it levied a penalty for not not following the law, something Congress has done many times before without incident.

The counterargument was literally invented out of whole cloth for the sole purpose of being applied to Obamacare: namely that Congress can penalize actions, but not inactions. Antonin Scalia made this famous as the "broccoli test." In two centuries, no one had argued this before. The Supreme Court had never breathed so much as a word about this distinction.

But conservatives were eager for the Supreme Court to take this hairsplitting argument and apply it not to a small and modest law as a future warning for lawmakers, but to perhaps the most consequential law enacted in the past half century. No member of Congress could possibly have imagined that this distinction between action and inaction would matter, since liberals and conservatives alike had proposed health care mandates before and no one had suggested it might be a problem.

So I agree with Ponnuru. I would very much like to hear what Gorsuch thinks about how freely the Supreme Court should set aside federal law. Should bigger laws require bigger reasons? Should it matter whether the Supreme Court has provided any guidance before? Should it matter how new and creative the argument is for overturning a law? Should Congress be given more deference in some areas than others? Which ones? Should it matter how big the consequence is of violating a law? These all sound like very interesting questions to me.

Lunchtime Video

Somebody asked for more ducks, so here they are. But I have two questions.

First, what are these ducks fighting over? It can't be a crumb of bread somebody threw to them. Maybe a fish? Do ducks eat fish? Or are they just ganging up on some poor duck who violated duck protocol? There's definitely a duck at the beginning who's getting pretty abused, but there seems to be more going on than just that.

Second, is this as good as resolution gets on YouTube? It seems like I've seen better. But this is HD video shot in MPEG 4, and I think I have all the settings correct. Is there anything more I can do?

UPDATE: We have answers!

  1. It's spring, when a young duck's fancy turns to thoughts of love. Among mallards, this is apparently a bit of mild foreplay. Be glad you're not a female duck.
  2. I'm an idiot. The video was in high res, but I had it set to display on my computer at normal res. Once I chose the high-res setting, everything was fine.

Paul Ryan says he's heard the pleas of older voters, who say that his health care bill will hurt them badly:

“We believe we should have even more assistance — and that’s one of the things we’re looking at — for that person in their 50s and 60s because they experience higher health care costs," the Wisconsin Republican told Chris Wallace on "Fox News Sunday."

Ryan's comments came in the wake of a Congressional Budget Office analysis showing that older people could pay higher premiums under the GOP bill. Ryan expressed skepticism about the CBO analysis but said his leadership team is looking at more ways to help older people under the new plan.

It's funny, isn't it? His health care bill would also decimate the poor, but apparently Ryan hasn't heard their pleas. I wonder why?

Who would get hurt by the Republican health care plan? The short answer is: pretty much everybody. But Andrew Sprung suggests a more precise way of looking at it, which he calls Total Subsidized Share of Costs, or TSS.

It's a pretty simple concept. If, say, the government pays half your health care premium, and your policy covers half your medical expenses, then your TSS is the product of those two things: one quarter. The other three-quarters you have to pay yourself. If (more realistically), Obamacare pays 85 percent of your premium, and the policy covers 80 percent of your costs (i.e., it has an "actuarial value" of 80 percent), then your TSS is 68 percent and you pay the other 32 percent. Since CBO calculated actuarial values for the Republican bill, we can calculate TSS for both Obamacare and AHCA.

My purpose on earth is to put other people's numbers into colorful charts, so let's do that. But first, I happen to think that a better measure to look at is not how much is subsidized, but how much the covered person has to pay. So instead of TSS, let's look at the inverse: Total Personal Share of Costs, or TPS.1 Here's my TPS report for various income levels:

If your income is $34,000 or less, Obamacare is a better deal for everyone. At higher income levels, Obamacare is still better for older people but AHCA is better for young people.

Of course, someone earning $40,000 or more is likely to have a job that provides health insurance, and therefore doesn't need either Obamacare or AHCA anyway. For nearly all the people who actually need individual health insurance in the first place, the Republican plan is a disaster. Poor people will all pay at least 60 percent of their health care costs, and older people will pay more than 80 percent.

1Astute readers will recognize another reason that I like the acronym TPS.

Today's big event is the testimony before Congress of FBI director James Comey and NSA chief Mike Rogers. Everyone seems very excited about this except me. Let's listen in:

“The F.B.I., as part of our counterintelligence effort, is investigating the Russian government’s efforts to interfere in the 2016 president election,” [Comey] continued, adding that the investigation included looking at whether associates of Mr. Trump were in contact with Russian officials, and colluded with them.

....Mr. Comey told the House intelligence committee, “We have no information to support” President Trump’s assertion on Twitter that President Barack Obama tapped Trump Tower.

....The N.S.A. chief, Admiral Rogers, weighed in as well, saying that he had no knowledge of anyone asking the British or any other ally to wiretap Mr. Trump. That refuted another claim made by the White House....He then explicitly denied having any indication that Mr. Trump was wiretapped by British intelligence at the request of Mr. Obama.

So the FBI is investigating possible ties between Russia and some of Trump's campaign aides, but Obama didn't order any kind of wiretap or surveillance of Trump Tower. We already knew this, right?

Now, none of this means there was any Trump-Russia collusion, nor that there was no surveillance of Trump. The first is still under review, and the second could have been ordered as part of a criminal investigation that Obama had nothing to do with. But it does mean, essentially, that Trump's March 4 tweets were just made-up rubbish based on a Breitbart story that someone stuffed into his pile of reading material. Of course, we already knew that too, didn't we?

Last night I posted a Gallup chart showing the job approval ratings of the four most recent Republican presidents among Republicans. Unfortunately, I bolluxed it up, so I deleted the whole thing. But now it's morning and I have time to create the correct chart and make a more constrained point with it, so here it is:

The recent cratering of President Trump's job approval rating was getting some attention last night, but I think this is a more important chart. What really matters is whether Trump stays popular among Republican voters—and whether this rubs off on the Republican Congress. So far he has. Trump's popularity among Republican voters during his first two months is as good as any of his predecessors.

This is not everything, of course. Although the House (deliberately) and the Senate (by historical accident) are currently gerrymandered to favor Republicans, centrists still matter. And according to Gallup, Trump is bleeding support among those without a party: his job approval rating has already dropped six percentage points among independents. If that continues it could mean bad news for the 2018 midterms, followed by a one-term presidency. These indies are who Democrats should care about right now. Unless things change, the Republican base remains not just out of reach, but positively thrilled with President Trump.

The New York Times reports on the infighting at the White House:

Mr. Trump is not bothered by turf battles in his administration. He believes they foster competition and keep any one aide from accumulating too much power. He is even more enthusiastic about waging war publicly, believing that it fires up his white working-class base.

Meanwhile, the Washington Post reports on on the political appointees ensconced in each cabinet department to make sure everyone stays loyal to President Trump:

At the Pentagon, they’re privately calling the former Marine officer and fighter pilot who’s supposed to keep his eye on Defense Secretary Jim Mattis “the commissar,” according to a high-ranking defense official with knowledge of the situation. It’s a reference to Soviet-era Communist Party officials who were assigned to military units to ensure their commanders remained loyal.

I have read frequently about both of these practices, which often go together. They are popular among vicious, paranoid autocrats. I don't believe I've ever read about this combination in a leader who is both admired and respected. Just sayin'.

This Gallup poll has been making the rounds today:

I've deleted the rest of this post. It was a comparison of job approval ratings of Republican presidents among Republicans. But I screwed it up. There's actually nothing interesting to report on that score. Trump's job approval ratings are about the same as Reagan, Bush Sr., and Bush Jr.