james debate
james debate

Friday 28 July 2017

The first months of the Donald Trump presidency have seen little in the way of legislative accomplishment. Without getting too speculative, there are many reasons why this Congress and this White House have not been especially productive, but chief among those reasons would have to be the heavy focus to date on healthcare. Indeed it has been all over the news, to the point where even the politically apathetic are probably aware that Trump and the Republicans are trying to do something with healthcare. The headlines have been full of buzzwords like "Trumpcare",  and "Obamacare repeal". Indeed Trump himself has declared frequently that Obamacare is already "dead". But what does all this actually mean, what exactly is/has/will be done, and what does it mean for the American patient?

trump obamacare trumpcare make america sick incompetence repeal death panels mccain

What is Obamacare?
The Patient Protection and Affordable Care Act ("ACA"), frequently referred to as "Obamacare" was a wide-ranging reform of American healthcare passed into law by then President Barack Obama. I will refer to it as Obamacare in this article, as this is the term with which most will be familiar.

Without getting too bogged down in the detail provisions of this law include children being able to stay on their parents' healthcare plan until the age of 26, greater protections for patients who would otherwise be refused insurance for having "pre-existing conditions", and tighter regulations on when patients can and can't be refused care. It greatly expanded the existing Medicaid program to cover anyone below a certain income threshold, and provided significant investment to medical research and healthcare infrastructure in order to bring the system into the 21st Century (these included, for example, online health insurance exchanges to give people greater freedom to find a plan that fits their needs).

All of this was paid for through a combination of new taxes, mostly targeted at the wealthy, and through a so-called "insurance mandate", which ultimately was more of a tax on people who did not buy health insurance, therefore incentivising otherwise healthy people to buy insurance and therefore contribute to the insurance pool for those who need it.

The effect of this law has been to expand healthcare coverage in the United States, achieving nearly universal coverage, and to control rising premium costs, which have largely stabilised since the law's passage. As a result of these benefits, Obamacare is generally a very popular law, scoring a high plurality or low majority of support in most recent polls, comparable with most laws that get passed. The specific provisions themselves have proven to be wildly popular in polls.

Obamacare is fairly popular, so why do Republicans oppose?
Describing the Republican opposition to Obamacare is difficult. For sure there are many things that can be improved with Obamacare, many things that need to be fixed, many bugs to be remedied. Strangely, these problems never get mentioned by Republicans, instead they have objected to the law from its inception for other reasons, including:

  • It was rushed into law, despite being debated over a 10 month period;
  • It was passed without any Republican input, despite the fact that votes were held on over 100 Republican amendments, many of which were ultimately included in the law, and despite the fact that many of the law's key provisions were based on previous Republican proposals;
  • The so-called "insurance mandate", despite this having been a key pillar of Republican healthcare policy since the 1960s, part of their national proposal in the 1990s, and part of many Republican Governor's statewide policies;
  • The expansion of Medicaid as an overreach of Government, despite many Republican Governors opting into the new expansion, and doggedly defending it during the current "repeal" debates;
  • New taxes.
As you can see, the logic behind many of these objections can be a bit inconsistent, and that's without even mentioning the ones like "death panels" and "Government takeover", which in retrospect are probably even embarrassing to the Republicans who used them. The only one on that list which doesn't require doing a complete 180 on longstanding Republican policy is the objection to new taxes. Strangely, there has been almost no noise about the actual flaws with the law, like the Medicare Part D donut-hole. Many more cynical observers have suggested the real reason has more to do with simple tribalism; Obama did it, therefore we oppose it. 

Whatever the reason, a full repeal of the law has been a core part of the Republican platform these past eight years, and now that they are in power with the White House and both chambers of Congress, many had expected them to follow through on this ambition.

The Republican Healthcare Plan
So what exactly have Republicans been proposing? What have they accomplished so far? Is Obamacare "dead" as Trump claims?

First thing is first. Obamacare is most certainly not "dead" despite the President's soundbite. It is still very much law, and that won't change until a full repeal of the law is passed by the House of Representatives, by the Senate (almost certainly requiring a filibuster-proof 60 vote majority), and then signed by the House. This has not happened yet, and as such the law is still law, and essentially unchanged from its status under Democratic governance.

So far, the House of Representatives has passed the American Healthcare Act of 2017 ("AHA"). The Senate has voted against this bill, and has also voted against two additional healthcare bills, the Better Care Reconciliation Act ("BCRA") and Health Care Freedom Act ("HCFA"), the so-called "skinny repeal". So at the moment, the Senate has voted "no" on three separate bills. If they vote yes on the House-approved AHA they can send it straight to the President for signature. If they vote yes on either of the other two, the House then needs to vote on it first. If the House and Senate can't agree on legislation, the two will enter a committee process in order to come up with a compromise bill, if one is possible.

So the current state of play is... not much has changed. The Republican controlled Congress so far can't agree on a bill to pass into law, and therefore the law remains unchanged.

But Obamacare WILL be dead, right?
So Republicans can't agree on a way to repeal Obamacare, but surely it's just a matter of time. After all they control the White House and both chambers of Congress. Surely they will eventually come up with a compromise and repeal that Obamacare once and for all, right?

Well actually, none of these bills, literally none of these bills, will repeal Obamacare. 

A repeal of Obamacare, actually removing it from law, will require 60 votes in the Senate. Republicans currently have 51, and no Democrat has shown themselves so far to be interested in cutting back people's access to healthcare. As a result, all of these proposals so far are so-called "budgetary reconciliation" bills, effectively just a budgetary adjustment of existing law, which only requires 51 votes to pass the Senate. 

So they're not even voting to repeal Obamacare?
Nope, they're voting to defund specific parts of it, a process which can be just as easily undone by the next Government, and has absolutely no longstanding effect on the Obamacare law itself. None of these laws repeal Obamacare, they just defund healthcare in America.

So why is Trump calling Obamacare "dead"?
Because he's a salesman, and he knows that the only thing voters care about is the perception. Make no mistake, if he could repeal Obamacare and replace it with an identical law called "Trumpcare", he would do it.

So do these bills actually do anything?
Yes, still very much so. The actual impact depends on the bill in question, but range from taking away access to healthcare from 22 million people (in AHA and BCRA) to 16 million people (in HCFA). All the bills in question would increase premiums significantly.

So these bills may not be an actual repeal of Obamacare, but their effect on sick people would still be significant. The good news is they can be easily undone by the next Government.

So where do we go from here?
Hard to say. The two likely scenarios are:
  1. Republicans pass some form of minor budgetary adjustment, declare Obamacare "dead". Next President just refunds Obamacare and we forget all about this charade.
  2. Republicans are unable to come up with a compromise and move on, defund healthcare services and then blame "Obamacare" for the deficiency.

What can we learn from all this?
The current Government is fairly incompetent, and they think the American voters are really stupid.

Thursday 6 July 2017

Directed by Sam Mendes
Written by Jez Butterworth
Starring Paddy Considine, Laura Donnelly, Stuart Graham, Fra Fee
Theatre Royal Court/Gielgud Theatre

ferryman royal court theatre gielgud butterworth sam mendes

It's by far the hottest ticket of the year so far. The Ferryman sold out instantly when it began its original run at the Royal Court Theatre. Now thanks to a mix of glowing reviews and the desire to thoroughly milk a cash-cow, Ferryman is transferring to the Gielgud Theatre on Shaftesbury, meaning those of us not fortunate enough to catch the fever first time around have a second chance to see what all the fuss is about.

Undoubtedly, part of the reason tickets sold out so quickly (and presumably one of the reasons they are so keen to recoup their expenses) is that Ferryman marks the much vaunted return to theatre of director Sam Mendes, former artistic director of the Donmar, more recently the Academy Award winning director of American Beauty and, of course, the recent James Bond movies. But for those of us who really love our theatre, Ferryman is at least as exciting for having been written by Jez Butterworth, last seen at the Royal Court with his excellent 2008 production Jerusalem. Does this ultimately justify being the fastest selling play in Royal Court history? Not necessarily, but hype aside Ferryman proves itself to be well worth the price of admission.

Set in 1980s Ireland against the backdrop of hunger strikes and IRA violence. The focus is on Considine's Quinn Carney, an ex IRA man now retired to life on his farm, surrounded by extended family and a bevy of foul-mouthed kids taking whisky with their breakfast. The core of the tension surrounds his relationship with Laura Donnelly's Caitlin, married to Carney's brother who has been missing for a decade, presumed killed by the IRA.

The quality of production is outstanding right from the start. The elaborate set design feels lived in and familiar. The lighting is ingeniously choreographed to unobtrusively create atmosphere, casting dancing shadows around the stage at key moments. The most striking example comes during an early moment of tenderness between the two lead characters, sharing a blindfolded slow dance by the light of the early morning. The heavily detailed set remains constant over the course of the evening, and yet the production team manage to introduce a remarkable level of flexibility, shifting mood and changing scenes between night and day, different furniture configurations and entrances, all in a seamless dream-like fashion. Sam Mendes shows here that he is still imposingly confident on a theatre stage, a man who knows exactly what he wants the audience to see and experience down to the smallest detail.

The cast is impressive, both in size and quality. A lovable noise of Irish characters, dancing, singing and sharing in bucolic family moments. It could easily have come off as a lazy parade of stereotypes, but it all gives way to a script far more deft and ambitious in scope than another writer might have delivered. Everything is presented in a larger context of history, tradition, familial tragedies, ancient feuds. At times it feels like there's so much baggage weighing these people down, that no wonder there are so many of them on stage, they simply can't leave.

Through the various weaving narratives and character arcs, a sense of profound loss unites their stories. The missing husband and brother, the doddering firebrand Republican who never stopped idealising a missing brother from childhood, the sleepy great aunt who intermittently emerges from senility to reminisce of lost romances, and lost history. By the end of the evening it will be clear why the name Ferryman has been chosen; an entire cast of characters appearing stagnant in a state of emotional limbo, waiting for something to snap so that they can finally move on.

As with Butterworth's other plays, this exceeds the sum of its narrative parts. More than just the family drama or period piece politics, this is a story that plays with your sense of nostalgia, evokes an all too relatable sense of hopeless longing, and builds a relentless intensity right until its denouement.

A play like this runs every risk of being dismissed as just another hype production, a fad of the moment, but that would do a disservice to what is ultimately another very fine addition to Butterworth's body of work. There is brilliance here, an excellent piece of theatre that I can wholly recommend anyone to take the time to enjoy. It's run at the Gielgud has just been extended, and if the tickets keep flying out the doors there's every reason to believe it will extend yet again. Make sure you catch it before it ends.

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