The Morning Jolt

Politics & Policy

Beware the ‘Virtually Eliminating Medicaid’ Argument

This is the last Jim-written Jolt until July 3 . . . unless National Review chooses to close that day for the Independence Day holiday, in which case I’ll return July 5. Enjoy the beginning of summer and the end of the school year. Also, if everyone on I-95 southbound in the states of Virginia, North Carolina, and South Carolina could get out of the left lane today, that would be great.

What You’re Going to Hear from Democrats about Medicaid

You’re going to hear quite a few Democrats charging that the Senate bill “virtually eliminates Medicaid entirely by the time we get to 2025.” If you look at the text, the “virtual elimination” looks an awful lot like a per-patient spending cap, which, whether you like this idea or not, isn’t really elimination. By this standard, any reduction in defense spending is the “virtual elimination” of the U.S. military.

The year 2025 brings the big changes:

Both the House and Senate bills aim to set a per-person cap on Medicaid spending in each state. That cap would adjust annually to take into account inflation. Through 2025, both bills would adjust the cap based on a measure of how rapidly medical costs are expanding — a measure known as the CPI-M.

Starting in 2025, however, the Senate bill would change the formula, instead funding Medicaid based on a measure of how rapidly all costs are rising (technically, the Consumer Price Index for urban consumers, or just CPI-U).

General costs, however, typically rise more slowly than medical costs. After 2025, the increases to Medicaid would no longer be able to keep pace, with the gap growing each year. After a decade or two, that discrepancy would add up to of hundreds of billions of dollars.

It’s as if these people have never seen a Washington budget before. “We’re going to make the really politically difficult cuts to an entitlement program eight years from now, we swear.”

Our Kevin Williamson points out that this is a well-established bipartisan tradition of budgetary cynicism. The Senate plan promises the good stuff up front (retroactively repealing a 3.8 percent tax on investment income, including capital gains and dividends, starting January 1) and the unpopular cuts down the road. The Democratic plan did it in reverse to hide the fact that too much money was going out and not enough money was going in:

The Affordable Care Act was designed in a dishonest way, front-loading the revenue and backing in the expenses in order to get a nice budget score from the Congressional Budget Office. The CBO rolled its institutional eyes at this, and its report suggested very strongly that its analysts did not believe a word of what they were writing, inasmuch as the most popular parts of ACA were likely to be enforced while the unpopular bits — like the “Cadillac tax” — would be put off or softened, resulting in a program that in reality cost much more and produced less revenue than it did in the model version that CBO scored. Sure enough, Hillary Rodham Clinton and Bernie Sanders both campaigned against the Cadillac tax (it hits their union foot soldiers first and hardest) while the House and Senate Republican plans would keep in, in theory, but put off collecting it until 2025 — at which point the smart money would be on its being put off again.

Kevin compares the American health-insurance system to the Swiss system and points out that every system is a trade-off. There’s a lot to admire in the Swiss system with universal coverage, but to make it work, there is an extraordinarily strictly-enforced mandate to purchase insurance, high copays, and no employer-based insurance.

An insurance system works when a lot of people pay into the system and get little or nothing in return. Most years, you don’t need anything from your auto insurance company. (At least, I hope you don’t!) The happy little gecko takes your money, you drive safely and avoid accidents, and the happy little gecko only has to pay out money to a small portion of his customers, keeping the rest of the incoming money to pay for all the company’s expenses, including that gargantuan advertising budget. Your homeowner’s insurance or renter’s insurance operates the same way. Thankfully, incidents of home damage are pretty rare.

But everybody gets sick eventually, particularly as they age, and this is what makes running a health-insurance company more difficult. To make it work, you need a lot of people paying in and getting nothing in return, so that you can cover the costs of the people who need a lot of expensive care, and who will never be able to afford those hospital stays, surgeries, and prescription drugs out of pocket. You know those stubborn guys (and it’s usually guys) who refuse to go to a doctor when something’s wrong with them? They’re probably keeping the system afloat. A 2016 survey suggested that only 60 percent of men get an annual physical, and around 40 percent only go to the doctor when they think “they have a serious medical condition.” This is bad for their personal health . . . but probably really useful for the nation’s fiscal health.

Finally, Twin Peaks Kicks into a Higher Gear

As I mentioned to a friend this week, I’ll probably say, “I was just about ready to give up on Twin Peaks” a bunch in the coming weeks/months/years. Of course, you know me well enough to know that probably wasn’t true. But after six episodes that felt like a wildly uneven slog, the seventh episode that aired Sunday finally kicked the plot into a higher gear and strung together one intriguing scene after another.

One of the theories floating around among TP fans was that because this was originally planned as a nine-episode limited series, and then David Lynch, Mark Frost, and Showtime later agreed to make 18 episodes, a plot designed for nine hours is now being stretched out to twice as long, creating an extremely slow-moving pace of storytelling. Or perhaps the first six episodes represent “Act One,” setting up everything, establishing where all the characters are in their lives now, and we’ve finally begun Act Two, where the plot starts moving . . . 

Finally, the Log Lady’s clue starts to pay off. We, the audience, know she isn’t crazy, just cryptic, and so it’s been a long wait for the other characters to take her seriously. The missing pages from Laura’s diary describe the scene in Twin Peaks: Fire Walk with Me, when Annie appears in Laura’s bed (not a dream) and says, “the good Dale is in the Lodge and he can’t leave.”

The initial hostility of Cooper’s previously-unseen assistant Diane is nothing like what we expected unless . . . Diane had been the loyal friend, co-worker (and perhaps even love/infatuation) to Dale for many years. During the interrogation scene, we learn the possessed Cooper and Diane were together at her house a long time ago. It appears they’ve had a disturbing intimate encounter and then he disappeared, and the FBI couldn’t find him for more than two decades. Suddenly her hostility to Albert, Gordon Cole, and the entire Bureau makes more sense.

It is nice to see the late Warren Frost one last time, and as old Doc Hayward, he offers the unnerving clue that the last time he saw Cooper, he was in the local hospital’s ICU, near the comatose Audrey Horne. The odds that local psychopath Richard Horne is the demon-spawn (almost literally) of Audrey and Cooper/BOB is now a stronger possibility.

We witness a rare moment of competence for Deputy Andy — he’s found the truck in the hit-and-run and the owner pretty obviously wants to tell him who was driving, but is afraid he’ll be seen talking to the cops. While it’s possible he skipped town, the ominous Laura Palmer’s theme music as we cut back to the house at the meeting time makes me think Richard Horne and/or the drug-smuggling ring got to this guy.

Even man-child Dougie finally gets to do something! While the bizarre vision of the Tree urging Dougie/Cooper to “Squeeze his hand off! Squeeze his hand off!” during the attempted murder was Level 11 surreal, it does sort of fit. The tree is the evolved form of “The Arm” and the Arm was the Little Man from Another Place, cut off from Mike/The One-Armed Man. Mike/The One-Armed Man is definitely a Black Lodge spirit (he takes some garmonbozia from BOB at the end of FWWM) but the interpretation that makes the most sense is that Mike/OAM is orderly evil while the demon BOB is chaotically evil. Mike wants evil deeds to be committed at a quiet, measured pace that keeps humanity in the dark about the existence of the lodges, while BOB wants as much garmonbozia (pain and suffering) as possible and has, in Leland and in Cooper, committed as much violent mayhem as possible.

The Little Man from Another Place was always mischievous or seemed to be teasing Cooper, but didn’t seem malevolent, and usually seemed to be working in tandem with Mike. Their preeminent goal in Season Three seems to be . . . well, “restoring balance to the force” and getting Bob back into the Black Lodge. Cooper’s comments in the first episode seemed to indicate that after 25 years, he would spontaneously return, thus the “Dougie” decoy. With both the “real” world and the spiritual world so imbalanced and chaotic — BOB wreaking havoc over 25 years, and Laura’s spirit seeming to be sucked away — even Mike is telling Dougie/Cooper, “You have to wake up. Don’t die. Don’t die.”

So when the hitman Ike the Spike, following orders from BOB/Cooper, shows up, the Tree has had enough of this nonsense, and urges Cooper to squeeze his hand off. Most creepily, Cooper seems to succeed in tearing off a chunk of flesh from his hand.

Most interesting development: Ben Horne seems to be trying to be a decent human being — he’s attracted to Ashley Judd, and it may be reciprocated, but he hasn’t made any inappropriate moves yet. We heard the reference to Audrey being in a coma; maybe he really did change for the better.

If you’re not a fan of Twin Peaks, and everything I’ve written above sounds like incoherent gobbledygook, my sympathies. As much as I enjoyed the seventh episode, I realize it’s something that’s almost completely inaccessible to a new viewer or a casual fan. Part of the joy is that everything has to be decoded and interpreted and discussed and analyzed; a show that always rewarded obsessive watching now almost requires it.

ADDENDA: The Three Martini Lunch will continue in my absence — coming soon to NPR One! — but I have no idea if next week shows will continue the tradition of Die Hard references. You have to listen carefully for Greg Corombus’s “We’re gonna need some more FBI guys” in yesterday’s edition.

Part of my vacation reading: Brad Thor’s latest thriller novel, Use of Force. Expect a full review when I get back.