Margaret Hartmann wrote an excellent article in New Yorker Magazine about the search for a scapegoat for Trumpcare now that the Congressional Budget Office states that 24 million people will lose health coverage by 2026 under the Republican health-care. More and more Republicans are coming out against the current version of the legislation — and pointing fingers at each other.  The Wall Street Journal reported Tuesday that at least a dozen Senate Republicans, “including some who had previously kept a low profile in the health debate,” have expressed serious doubts about the legislation making its way through the House. The report poured cold water on the theory that passage in the House would build enough momentum to get the AHCA though the Senate.

The most obvious target is the man behind the bill; Breitbart’s escalating attacks on House Speaker Paul Ryan have added fuel to suspicions that chief strategist Steve Bannon hasn’t given up on his goal of ending Ryan’s career.

Breitbart is far from the only conservative outlet bashing “Ryancare.” Newsmax chief executive Christopher Ruddy even published a piece urging President Trump to abandon the current bill.

According to the Huffington Post, Republicans may already be giving up on getting AHCA passed in the Senate.

“The focus of House leadership has been more about getting a bill out of the House that is unchanged and in keeping with the Better Way plan, instead of truly seeing to potential roadblocks that exist in the House and Senate,” said a Republican House member.

“The question people should be looking at is whether Republican senators like Tom Cotton and Rand Paul are actually interested in repealing Obamacare, or whether they’re sabotaging this to preserve the Medicaid expansion in their states,” said the aide. “These senators masquerading with conservative objections are too afraid to admit they want to keep Obamacare.”

Of course, as President Trump has stated several times, the Republicans’ preferred “Plan B” is to keep blaming Senate Democrats. As the Huffington Post notes, there’s a major flaw in that strategy:

If Trump and some Republicans now think their best course of action is to do nothing and continue blaming problems with the health-care system on Democrats, then perhaps the best cover they can offer their members is to move a GOP bill out of the House, watch it die in the Senate, and then spend the next two years blaming Senate Democrats in states that Trump won.

In that scenario, voters fail to recognize that Republicans have the power to pass this bill without a single Democratic vote, and the ire over Obamacare doesn’t dissipate even though voters have seen the GOP alternative.

Will voters remember that Trump promised an Obamacare replacement “that’s going to be better health care for more people at a lesser cost,” then failed to put much energy into crafting that plan? Maybe, but blaming other people for his mistakes happens to be one of his strong suits.

Bob Doherty, senior vice president for government affairs at the American College of Physicians, the trade group for internists and the second-largest association of doctors in America, is taking a different approach on Twitter, blasting the bill as the worst measure he’s seen in nearly 40 years of advocacy work.

Doherty warns of “thousands of preventable deaths” if the bill passes (which checks out), as 28 million people lose coverage. He also makes the point that the long-term health consequences of the bill could be even more severe, as older people who lose insurance coverage due to skyrocketing premiums “will put off getting care until diseases are at more advanced, less treatable, & costly stage.”

In 38 years advocating for doctors, patients I’ve never seen a bill that will do more harm to health than bill being voted on Thursday

It will take coverage from millions of most vulnerable: the poor,sick & old. It will raise premiums & deductibles by thousands of $.

It will make the opioid epidemic worse by ending requirement that Medicaid cover substance use treatment.

It cuts Medicaid funding by 25%; states will have no choice but to cut coverage & benefits and/or raise taxes, cut provider pay.

It cuts funding to @CDC to prevent spread of infectious diseases like flu and Zika.

Proposed work requirement for Medicaid punishes those who can’t work because they are sick, have mental health conditions, are caregivers

Or because there are no jobs.

It will cause people to forgo doctor visits, and prevention /screening tests and not keep up with medications.

They will put off getting care until diseases are at more advanced, less treatable & more costly stage.

Lives are at stake: loss of coverage associated with thousands of preventable deaths.

This bill has to be stopped. Call Congress today. 2022243121. Urge them to vote against . Don’t wait. Vote is on Thursday.

Trumpcare Facts:

The plan would hit older and rural Americans hardest because it wouldn’t provide a larger tax credit to people with more expensive plans.

The plan would reduce Medicaid spending by $880 billion, though Trump repeatedly promised no cuts to the program when battling his primary opponents.

Tucker Carlson raised this point with President Trump during a Fox News interview. “I know that, I know,” the president said, as the host cited Bloomberg’s finding that Trump-supporting counties would be hammered. “It’s very preliminary.”

“This isn’t consistent with the message of the last election,” Carlson said. “No, a lot of things aren’t consistent,” Trump acknowledged.

Eugene Robinson wrote a great article for PennLive about the myth of Republicans as the party of fiscal responsibility. The Republican Congress is pushing Trumpcare before the Congressional Budget Office has had a chance to estimate how much the measure will cost.

“It’s time to put an end to the myth that Republicans believe in fiscal responsibility. Saving taxpayer dollars takes a back seat to the ideological imperative of blaming and shaming the poor.”

“When you ask Republicans what they’re going to cut, they mention foreign aid — which totals about $35 billion, or slightly less than 1 percent of federal spending.

They threaten to eviscerate smaller agencies by cutting $6 billion here or $8 billion there — but at the same time, they applaud Trump’s pledge to increase the $600 billion defense budget by an incredible 10 percent.

They’re going to end up spending more — perhaps lots more — and collecting less in tax revenue. And this is the party that claims to care about deficits and debt?

But wait, Republicans say, we’re going to “save” the big entitlement programs by trimming benefits. Yeah, sure. I’m not holding my breath.

The problem is that Medicare and Social Security serve middle-class and upper-crust taxpayers, including many who share the GOP’s punish-the-poor belief system. If you think these ACA-focused town halls are hostile, just you wait.

The fact is that among recent administrations, at least, Democratic presidents have been the relative skinflints. Bill Clinton, you will recall, actually balanced the budget — and yes, he had help from Republicans in Congress.

Barack Obama spent heavily at first to save the economy, which was teetering on the edge of a dreadful abyss, but he ended up slashing the deficit in half and presiding over years of uninterrupted economic growth.

George W. Bush, on the other hand, fought hugely expensive wars in Afghanistan and Iraq without accounting for them in his budgets.

He also convinced Congress to expand Medicare to cover prescription drugs, which was compassionate but costly.

Trump promises to be even more of a big spender. Among other things, he promises a trillion-dollar program to renew the nation’s infrastructure. Imagine the Republican howling if Obama had suggested such a thing.

The GOP will surely persist in its sanctimony about balanced budgets, but no one should pay any attention. Republicans, we see what you’re doing.”

According to a report in Politico, the number of GOP governors who have “expressed strong support” for their party’s plan is exactly zero, while 15 have voiced varying concerns.  Republican governors object to Medicaid federal allotments to the states limited by a per capita cap. Unfortunately, Trumpcare has the spending cuts without the flexibility.

 As Health Affairs notes, AHCA may actually be more prescriptive than the status quo, micromanaging several types of beneficiaries the authors do not want to receive coverage (e.g., lottery winners, the undocumented, those with home equity over a certain amount), without some general grant of flexibility.

The sought-after flexibility isn’t there:

The combination of federal funding reductions and the retention of the program’s comprehensive legal requirements would, in effect, create a perfect storm for states. While it is possible that some of these requirements could be eased by the Trump Administration using its section 1115 waiver authority, section 1115 is actually a limited research and demonstration statute, not a tool for wholesale statutory re-design simply to create new state flexibility. Furthermore, certain Medicaid provisions, such as premium and cost-sharing rules, are by and large excluded from the scope of 1115.

The GOP governors have noticed this disrespect from the authors of AHCA:

“Flexibility” has become a buzzword among governors critical of the bill. Baker, Snyder, Arizona’s Doug Ducey, Tennessee’s Bill Haslam, Wisconsin’s Scott Walker and Nevada’s Brian Sandoval say there is work to be done on the bill to ensure it grants the states the flexibility they need.

“The plan that was released doesn’t reflect what the governors want, which is flexibility,” Ducey told a local radio station in Phoenix. “I want flexibility at the state level to improve our health care system, to make these reforms. This is still prescriptive from Washington, D.C.”

Meanwhile, the Republican governors of Ohio, Nevada, Michigan, and Arkansas jointly declared their opposition to the bill, in a letter to Mitch McConnell and Paul Ryan. Like the Senate moderates, John Kasich and company want to preserve the increased level of federal funding that Obamacare provides Medicaid recipients — and, if cutbacks are needed, to limit eligibility rather than reducing reimbursements.

In other words: The governors don’t want Paul Ryan to take away the free money that’s keeping their low-income residents insured and their hospitals paid.

While governors, obviously, won’t get a vote on the AHCA, Republican senators from expansion states are subject to similar pressures. And on Friday afternoon, Nevada’s Dean Heller said he stands with his governor.

As part of Obamacare, the federal government increased payroll taxes to help pay for the Medicare Trust Fund. That fund is used to reimburse hospitals when seniors come in and need treatment.

Trump’s bill does away with those new taxes. As a result, the Medicare Trust Fund would go broke about four years earlier than currently projected, in 2025 instead of 2029. This would either force hospitals to either swallow the costs themselves, turn away Medicare enrollees, or both. Here’s what the tax repeal would do to the trust fund, according to the Brookings Institution:

Repealing the ACA’s tax on high income households and hospitals would exhaust the Medicare Trust fund by 2024 http://brook.gs/2hSsObR 

The Washington Monthly had an interesting take on the Republicans’ difficulty replacing Obamacare.

As this mess unfolds, it’s worth remembering that the Republican Party has had eight years since the passage of the ACA to consider what it would do instead, given control of all three branches of government. Eight years for all of its policy wonks to design a plan that would provide, in Trump’s words, “insurance for everybody” that is “much better and much less expensive.”

The problem is that the only way to provide better, less expensive care for everyone that improves on the ACA is the universal, government-backed insurance offered by nearly every other developed country in the world. Allowing insurers to sell across state lines would create a regulatory race-to-the-bottom and do almost nothing to lower costs. Most Americans have so little in savings they can’t retire or put their kids through college, much less cover $500,000 of cancer treatments through an HSA. And covering people with pre-existing conditions through market processes requires a mandate to make it work.

Republicans know all of this. They know it because the ACA is actually the conservative, market-based alternative to single-payer. It was essentially was the Heritage Foundation’s alternative to Hillary Clinton’s 1993 healthcare plan. It became the basis of Romneycare, the plan backed and enacted by the 2012 Republican nominee for president. It’s the Republican alternative to single-payer.

That Republicans have been so adamantly hostile to it represents jaw-dropping political hypocrisy and opportunism. The pre-Obamacare status quo theoretically served their donors better because it contained fewer taxes on the rich, but it was also an escalating national crisis that needed solving. The lack of a Republican solution on healthcare was a big driver of Democratic votes. But rather than be a responsible partner in fixing the problem in a way that pleased conservatives as much as possible, Republicans played political gamesmanship. They called their own plan a socialist abomination with death panels. They scared seniors into thinking that their own Medicare would be snatched away in order to give healthcare to the unworthy–even as they plotted to defund and privatize Medicare themselves. It was a con of breathtaking proportions, and it worked. Lies, outrage and fear over the ACA were big drivers of the 2010 and 2014 Republican wave elections from which the Obama Administration never recovered.

But Republicans still don’t have an alternative plan for solving the healthcare crisis. They never did. That’s why the AHCA looks so much like the ACA, only stingier and less competent. The true believers on the far right want a fully libertarian system, but the more sober folks in leadership know the public health catastrophe that would cause would destroy Republicans electorally for a generation. The few Republican moderates want a GOP facelift on the ACA that doesn’t endanger them too much. Trump knows nothing about healthcare policy at all, and just wants to check off a box on his list of things to anger liberals about.

But none of them ever expected to be here, and they never had a plan.

A recent article in the Duluth News Tribune reported that Trumpcare would cap federal spending on Medicaid and force states, nursing homes, hospitals and others to make up the difference, which would grow over time. Medicaid has been a big part of the nation’s health-care system for over 50 years and insures nearly 1 in 5 Americans. One in every two people over the age of 65 will have some type of stay in a nursing home, with one in 10 staying longer than five years. Of those currently receiving nursing home-level care, 40 percent are under the age of 65.

A per-capita cap (sending a fixed amount to the states for each beneficiary) or a block grant (sending a fixed amount to the states for their entire program) would give states substantially less federal funding than they would get under Medicaid today, with the cuts growing larger each year.

“What a huge impact this could have, even here in Detroit Lakes,” said Janet Green, regional director of Ecumen, which owns Emmanuel Nursing Home in Detroit Lakes and manages Sunnnyside Care Center near Lake Park for Becker County.

With an aging population, Minnesota could be especially hurt by the proposed changes to Medicaid, which covers many nursing home residents.

“In Minnesota, there are a rising number of older adults and people needing Medicaid to pay for long-term health needs,” Green said.

Long-term care costs, based upon a recent survey by Genworth Financial, shows median costs for home care at $65,000 a year and a private nursing home room at $97,000 a year, according to University of Minnesota Extension. Costs like that can quickly consume a lifetime of savings, leaving people dependent on Medicaid for nursing home care.

Any cuts in Medicaid will mean less money to pay our staff,” she said. And nursing homes, for obvious reasons, are all about people—some 70 percent of total costs are for personnel. “As you know, we have a worker shortage in Minnesota, and we have a hard time paying staff as needed,” Green said.

Loss of federal Medicaid funding could have a detrimental effect on efforts to keep people in their homes longer and out of nursing homes.  But if funding for those programs goes away, more people will try to stay at home without services, and it will end up costing the system more in the long run. “People will be sicker and need more costly care,” she said.

Medicaid pays the premiums, deductibles, co-payments and other out-of-pocket costs associated with Medicare for lower-income elderly people, Medicaid changes could also hurt Medicare beneficiaries.

“Sometimes it’s all about money, and we’re not really looking at how it’s going to affect people,” Green said of the Medicaid proposal. “At the end of the day, we want to make sure we’re taking care of our elderly and vulnerable.”

A Florida federal jury in U.S. ex rel. Ruckh v. Genoa Healthcare, LLC, found the operators of 53 skilled nursing facilities liable for more than $115 million in damages stemming from false claims they submitted to Medicare and Medicaid after pretending patients needed and received more care than they did.

The jury ruled on False Claims Act allegations brought by whistleblower Angela Ruckh, who worked at two of the facilities as a nurse, and found that the four defendants — CMC II LLC, Salus Rehabilitation LLC, 207 Marshall Drive Operations LLC and 803 Oak Street Operations, LLC were liable for false claims.

Ruckh said she saw years of corporate scheming meant to “bill Medicare and Medicaid” by upcoding therapies.  Angela Ruckh, formerly of La Vie Management, proved that the providers listed in the case presented “false or fraudulent” claims for reimbursement.

The Government has many tools to help it prosecute False Claims Act cases.  One such tool is extrapolation—the act of using a sample of resident files to determine an error rate and applying that error rate to a greater universe of resident files.  After some initial setbacks including having their case dismissed for lack of necessary detail, the plaintiff complained that to show fraud with detail in every instance was not feasible.  The plaintiff instead asked to use the Government’s tool of extrapolation (to be able to have an expert pick out some files, determine an error rate and apply that error rate to a larger universe.)  The Federal Government filed a brief in support of permitting private parties this power.

The Court sided with the whistleblower, allowing her to use extrapolation and statistical sampling to estimate the volume of overpayments allegedly received by the defendants.  In issuing his decision, District Judge Steven Merryday relied on other cases that accepted statistical sampling methods as reliable and acceptable evidence in determining facts related to False Claims Act claims.  Judge Merryday echoed a recent District Court case in Tennessee that considered “the large universe of allegedly false claims” in finding that “it would be impracticable for the Court to review each claim individually” and to do so “would consume an unacceptable portion of the Court’s limited resources.”

Though this case is just the latest in a string of cases upholding the use of statistics and extrapolation to establish liability under the False Claims Act, this decision is unique in that it allows an individual qui tam whistleblower to utilize this powerful tool to demonstrate falsity even where the Government has declined to intervene in the case.