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The dirtiest little secret of the Republicans Obamacare repeal campaign is that its genesis has nothing to do with the Affordable Care Act as such, but with a long-cherished desire to gut Medicaid, which predated the ACA by nearly a half-century.

To advance this goal, conservatives and GOP leaders have asserted consistently that Medicaid doesnt work or even harms its beneficiaries. Health economist Austin Frakt of Veterans Affairs and Boston University now has done Medicaids defenders an important service by issuing a call to collect in one place all the claims that the program is broken or harmful, and then pointing us to research debunking those smears.

To be fair, the goal of gutting Medicaid as part of Obamacare repeal isnt really much of a secret. House Speaker Paul Ryan, R-Wisc., gave the game away in a videotaped discussion with National Reviews Rich Lowry in March. There he confessed, So Medicaid, sending it back to the states, capping its growth rate, we've been dreaming of this since I've been around since you and I were drinking at a keg.... I've been thinking about this stuff for a long time.

Ryan is 47 now, so he would have been dreaming about cutting Medicaid in the early 1990s while drinking at a keg, perhaps at frat parties at his alma mater, Miami University of Ohio. The ACA was enacted in 2010.

Other examples abound of Republican and conservative hostility to Medicaid. A 2013 survey of 13 state governors who opposed its expansion under the ACA found five who listed as a principal rationale that its a broken system [that] harms its beneficiaries. Health and Human Services Secretary Tom Price told a congressional hearing in March that Medicaid has decreased peoples ability to access care. The right-wing American Action Forum says the program is harming those who need it most.

We reported last week on a drive-by attack on Medicaid wholly unsupported by the facts launched by right-wing pundit Ben Domenech on the CBS program Face the Nation, and on right-wing healthcare commentator Avik Roys long crusade against the program.

In this video posted in March, House Speaker Ryan confessed that he's been out to gut Medicaid since long before the Affordable Care Act existed

In this video posted in March, House Speaker Ryan confessed that he's been out to gut Medicaid since long before the Affordable Care Act existed

In perhaps the most appalling example, Seema Verma, who as the administrator of HHS Centers for Medicare and Medicaid Services is in charge of the program, cast doubt in an op-ed last week that Medicaid works for those it was designed to serve. Verma based her conclusion that Medicaid had justifiably taken a lot of heat in recent years on three studies that have been widely questioned and even more widely misinterpreted.

None of these claims is true. So lets look at this evidence.

Heres a short-cut version, produced in 2011 by Frakt and co-authors Aaron Carroll, Harold Pollack and Uwe Reihardt: If Medicaid actually harmed health, instrumental variables studies would show that; they don't, they wrote in the New England Journal of Medicine. Other complementary research, such as the RAND Health Insurance Experiment and studies of patients 65 years of age or older who were uninsured before entering Medicare, support the belief that basic public health insurance coverage improves health.

One of the most oft-cited studies questioning the efficacy of Medicaid is a 2010 study of surgical outcomes from the University of Virginia. The 900,000 surgeries in the sample were from 2003 to 2007. The researchers found that in-hospital mortality for Medicaid patients was worse than for uninsured or privately insured patients, though lower than Medicare patients.

But as an analysis by the Milbank Memorial Fund observed, there were lots of questions about this conclusion. The Virginia researchers tried to adjust for some risk factors distinguishing the Medicaid population from the others, but they couldnt adjust for everything.

Among the factors they acknowledged might contribute to mortality and skew the results, the Medicaid patients had the highest incidence of AIDS, and metastatic cancers, depression, liver disease, neurologic disorders, and psychoses. They suffered from social factors associated with poverty, including drug abuse and delayed diagnoses, and lacked support and resources for care at home.

Despite all that, it turned out that Medicaid patients actually did better than some other patients in such surgeries as lung resections, pancreatectomies, and aortic aneurysm operations, and had fewer complications in some categories. A blanket conclusion that Medicaid patients did worse simply was unwarranted.

Its also the case, as Kevin Drum of Mother Jones points out, that mortality is an inadequate metric for assessing a healthcare program, since the vast majority of doctor visits arent for life-threatening conditions. But they can be for conditions that can profoundly affect ones quality of life, not to mention ones financial condition, if they go untreated. In any case, he adds, since the average age of Medicaid enrollees is 38, there wont be much mortality in that group to begin with, so any changes are unlikely to be meaningful.

The best-known study of the effect of Medicaid coverage is the so-called Oregon Experiment, which has the best pedigree of all such studies: It was done by researchers at Harvard and MIT, including such supporters of universal healthcare as Jonathan Gruber. Medicaid critics constantly cite it as proof that having Medicaid coverage is no better than being uninsured, to quote Avik Roy.

New England Journal of Medicine, via Kevin Drum, Mother Jones

No better than uninsurance? Really? Medicaid significantly reduced the financial strain on its enrollees in Oregon.

No better than uninsurance? Really? Medicaid significantly reduced the financial strain on its enrollees in Oregon. (New England Journal of Medicine, via Kevin Drum, Mother Jones)

The problem here is that the authors of the study disagree with that. The study, which followed newly enrolled Medicaid patients for two years, found no improvement in three markers associated with cardiac health and diabetes: cholesterol, high blood pressure and blood sugar levels. But the figures for those were not statistically significant, which makes them useless for assessing the programs effects.

The researchers did, however, find a statistically significant reduction in the incidence of depression, a significant increase in the diagnosis of diabetes and the use of diabetes medications, and in cholesterol screening, pap smears, mammograms and other screening tests. They also found a significant reduction in financial strain from medical costs. Catastrophic expenses, defined as those exceeding 30% of income, were nearly eliminated.

These benefits can be traced directly to Medicaid coverage, and theyre not trivial. The fact that Medicaids critics return to the Oregon results over and over, cherry pick a few findings, and misinterpret those should tell you something. Its that declaring Medicaid to be useless, or no better or even worse than having no insurance at all is merely a shibboleth.

Its an incantation that gets endlessly repeated as truth, even though empirical studies show that theres no truth in it at all. Verma, by citing both the Virginia and the Oregon studies in her op-ed without acknowledging their limitations, turned in a shameful performance.

The congressional Republicans backing the Obamacare repeal bills that cut the meat and bones out of Medicaid to the tune of $800 billion to $1 trillion, must have some ulterior motivation. It cant be improving its users health, because what theyre planning would achieve just the opposite. What could it be?

Keep up to date with Michael Hiltzik. Follow @hiltzikm on Twitter, see his Facebook page, or email michael.hiltzik@latimes.com.

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Republicans say Medicaid doesn't work, so it should be cut. Here are all the ways they're wrong - Los Angeles Times

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Despite tweets on Friday from President Donald Trump and several high-profile Republican senators, the "repeal, then replace later" option is not really on the table and isn't something that will be pursued by GOP leadership as they try to pull together the 50 votes they need to pass their health care plan. Negotiations are continuing as planned for a proposal that repeals and replaces Obamacare simultaneously.

As CNN reported Friday, there is almost no chance senators will vote on a health care bill the week senators return from recess. Expect the health care negotiations to be a multi-week process.

Senate Majority Leader Mitch McConnell is sending several different proposals and basic outlines to the Congressional Budget Office to help speed up the final scoring process, as CNN reported several times last week. Although the top White House legislative official, Marc Short, said Sunday on Fox News that McConnell sent two bills to CBO for scoring; that's not exactly the case. McConnell actually sent two outlines, plus several other proposals that may make it into a final bill.

The future of the proposal continues to depend on whether there is some compromise resolution on the same issues, including a softer landing for the eventual Medicaid reforms and how to craft some acceptable version of Texas Sen. Ted Cruz's regulations amendment into the final proposal. In his comments Sunday, Short appeared to give the White House endorsement to Cruz's regulations proposal, which if so would be no small thing.

Opioid funding and changes to regulations related to the use of health savings accounts appear to be settled and locked in.

A still looming, very real fight that will be coming when they return: whether to repeal the 3.8% investment tax in Obamacare or not. This is not at all settled, but sources tell CNN this is something that won't be dealt with until Congress returns to Washington.

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Here's where Republicans' health care plans stand - CNN

In a story that was ostensibly about new Supreme Court Justice Neil M. Gorsuch's voting record, NPR legal affairs reporter Nina Totenberg dropped this tantalizing piece of news about Justice Anthony M. Kennedy's potential retirement:

Kennedy may also have thought it best to ensure that there is a full complement of nine justices for at least a year. He could even have been put off by President Trump's tweets about the judiciary.

But it is unlikely that Kennedy will remain on the court for the full four years of the Trump presidency. While he long ago hired his law clerks for the coming term, he has not done so for the following term (beginning Oct. 2018), and has let applicants for those positions know he is considering retirement.

That's called burying the lead. And it's a piece of news that, especially after a tough first six months of the Trump administration, Republicans will be very, very happy to see.

It's not terribly surprising that Kennedy would consider retirement indeed, there was some thought he could even have announced it last week, when the court's term ended but this looks like a pretty good indicator that it will come at some point in President Trump's first term. If Kennedy is considering retiring in 2018, is he really going to stick it out until 2021, when he will be 84 years old? That seems even more unlikely now than it did before.

The upshot? It would mean thatDemocrats wouldn't have a chance to unseat Trump before the next big Supreme Court vacancy comes along. And not only that, but it would seem they may not even have a chance to stop it the other way: with a Senate majority. If Kennedy announces his retirement in advance of the term beginning in October 2018, logic suggests that the GOP would be able to fill it before that election.

Even if the vacancy is filled after the midterms, though, Democrats face a very difficult mapin November 2018. To win three seats and the Senate majority, they effectively need to win the two competitive states on the map Arizona and Nevada along with a very red state like Texas. Oh, and they also have to successfully defend a bunch of Trump states where Democratic incumbents are up for reelection.

Basically: If this vacancy happens before 2018, that's great for the GOP. But if it happens basically at any point in the next three years, that's likely to begravy, too. The key is for it to happen before late 2020.

And it's difficult to overstate the significance of all this.Indeed, if nothing else of real substance gets accomplished on Trump's watch, it all might have been worth it for the GOP merely for his potential appointment to replace Kennedy. Kennedy is the swing vote on a pretty evenly divided nine-vote Supreme Court, and replacing him with a more conservative justice would tilt the court further to the rightfor years or potentially decades to come.

Replacing Kennedy with a Gorsuch-esquejustice would give us five justices that were to Kennedy's right. And that, according to Andrew D. Martin's and Kevin M. Quinn's scores of the ideology of Supreme Court justices, would be basically unprecedented.

Here's how the Supreme Court looked between 1935 and 2015 before Antonin Scalia died and was replaced by the ideologically similar Gorsuch. Keep an eye on that yellow line for the median justice, and imagine it being John G. Roberts Jr. instead of Kennedy.

At that point, Democrats would basically have to hope that the George W. Bush-appointed chief justice would be more liberal than Bush intended. And then they'd have to hope that future vacancies come at much more opportune times.

(h/t Rick Hasen)

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Republicans just quietly got some very good Supreme Court news - Washington Post

If you thought the minimum wage only moved in one direction, then Missouri Republicans have a surprise for you.

After St. Louis leaders raised the wage floor for workers within city limits, the state GOP recently passed whats known as a statewide preemption law, forbidding localities from taking such matters into their own hands. On Friday, Missouri Gov. Eric Greitens (R) said he would let the law go into effect, thereby barring cities and counties from setting a minimum wage higher than the state level.

For low-wage earners in St. Louis itself, the new law will have a startling consequence: It will actually push the minimum wage back down, from the city-approved $10 per hour to the state-approved $7.70. The downgrade is slated to take effect on Aug. 28.

For someone earning the bare minimum, thats a potential cut of 23 percent.

HuffPost readers: Are you, or is someone you know, a St. Louis worker affected by this law? Email us about it.

Its impossible to say how many St. Louis employers will take the GOP up on the offer to slash pay, given the effect such a move could have on competitiveness and morale. But if businesses agree with Republicans that the city wage hike is too aggressive, then at least some of them are likely to revert to the lower pay rates, particularly in low-wage industries like fast food.

Greitens wasnt eager to own the state-sponsored pay cut, opting not to sign the bill. But he doesnt have to sign it for it to become law. Under the Missouri Constitution, a bill passed by state legislators eventually goes into effect so long as the governor doesnt veto it.

The governor said the St. Louis minimum wage would kill jobs. And despite what you hear from liberals, it will take money out of peoples pockets, he added, according to the St. Louis Post-Dispatch.

The Fight for $15 the union-backed campaign behind the St. Louis initiative and other wage-boosting efforts around the country called Greitens passive approval of the law disgusting.

If St. Louis' existing measure were to stay in effect, the citys minimum wage would be$10 this year and would then climb to $11 in 2018. The statewide rate of $7.70 typically goes up just a few cents a year, since its tied to an inflation index.

St. Louis originally passed a minimum wage hike two years ago, prompting business groups to sue to stop it in court. The Missouri Supreme Court recently ruled that the St. Louis measure was lawful, but the new state preemption law renders it irrelevant.

The concept of preemption laws has been around for years, but theyve become increasingly popular in GOP-controlled states as more cities and counties have tried to raise the minimum wage. Business groups have struggled to blunt local wage legislation and referendums, but they've had better luck convincing Republican state legislators to block them from the state capitol.

St. Louis is one of the more glaring case studies, since the wage floor will now sink lower due to a state law. But at least 17 states have preemption laws that stand in the way of local minimum wage legislation, according to a recent study by the National League of Cities.

In Alabama, GOP state legislators passed a preemption law taking aim at the city of Birminghams $10.10 minimum wage. The Alabama chapter of the NAACP ended up filing a civil rights lawsuit against the state, claiming that the majority-white legislature was disenfranchising Birmingham residents, who are 73 percent African-American.

The suit was originally dismissed but is now on appeal.

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Missouri Republicans Lower St. Louis Minimum Wage From $10 To $7.70 - HuffPost

The Illinois House on Sunday approved a major income tax increase as more than a dozen Republicans broke ranks with Gov. Bruce Rauner amid the intense pressure of a budget impasse that's entered its third year.

The Republican governor immediately vowed to veto the measure, saying Democratic House Speaker Michael Madigan was "protecting the special interests and refusing to reform the status quo."

The measure, which needed 71 votes to pass and got 72, is designed to start digging the state out of a morass left by the lengthy stalemate. Madigan, in a statement, praised the action as "a crucial step toward reaching a compromise that ends the budget crisis by passing a fully funded state budget in a bipartisan way."

The tax hike now heads to the Senate, but whether there will be enough votes to send it to Rauner's desk is in question. When the Senate approved its own tax hike in late May, no Republicans voted for it and several Democrats voted against it. Senators return to the Capitol on Monday.

The crucial vote in the House was the big story Sunday, though. Ultimately, pressure that had built up in districts across the state moved enough Republicans to defy the governor.

With state government operating without a budget for two full years, public universities risk losing their accreditation, social service providers are closing their doors and layoffs of road construction workers are imminent. Adding to lawmakers' anxiety was a promised downgrade of the state's credit rating to junk status, which could spike the cost of borrowing at a time when the state has $15 billion in unpaid bills.

Left out of the House budget package was a plan for dealing with the unpaid bills, though both sides generally agree that some amount of borrowing will be needed.

Rauner, a former private equity specialist from Winnetka, had spent tens of millions of dollars on legislative campaigns and TV ads to prop up the Illinois Republican Party as a counterweight to Madigan and his labor union allies. And Republican lawmakers largely had stuck by their governor until Sunday.

A pair of Downstate Republicans summed up the split.

"For me right here today, right here, right now, this is the sword that I'm willing to die on," said Rep. Michael Unes, a Republican from East Peoria. "And if it costs me my seat, so be it."

Rep. Terri Bryant, R-Murphysboro, said while she hated taxes, as a fiscal conservative she could not stand by while the state cannot pay billions of dollars in bills owed to small businesses.

Bryant teared up when explaining that she must do what is best for her district, which includes Southern Illinois University in Carbondale.

"I hope you will help me bring my university back," said Bryant, who added that she expected to face a primary challenge because of her vote.

Fifteen Republicans broke ranks with Rauner to join 57 Democrats in voting for the tax hike. A dozen Republicans were from Downstate, where many of the state's public universities, prisons and other state facilities are located. Another three were from the suburbs.

Getting so many Republican votes allowed 10 Democrats to vote against the tax increase. Six are from the suburbs and four Downstate, and all are potentially targeted for defeat next year by the Rauner-funded Illinois Republican Party.

Democratic leaders portrayed the vote as an attempt to let rank-and-file lawmakers from both sides do something to show their seriousness about putting an end to the budget stalemate in the face of concerns the state's credit rating will hit a first-in-the-nation junk status.

Republican leaders, though, saw it as a politically motivated attempt to force those in their ranks into a corner. Shortly before voting began, Democrats introduced revamped tax and spending plans, prompting House Republican Leader Jim Durkin to say the process had been "hijacked."

Following the vote, Durkin rejected the notion that the outcome amounted to a defeat for Rauner and Durkin's own leadership of House Republicans. The governor had kept out of the public eye during much of recent negotiations, and Durkin assumed the role of Rauner's proxy in the talks with Madigan and Democratic Senate President John Cullerton.

Durkin said House Republicans who voted for the tax increase succumbed to intense pressure made worse by the belief that Democrats would not cave on the changes Rauner wanted.

"There's going to be another vote on this, but the fact is we've done a pretty good job over the last three years hanging together," Durkin said. "I knew this was going to be a tough vote. I'll let my members decide how they characterize me after today. I've done what I could to operate in good faith and keep my caucus together."

Durkin noted that the vote may not mean Illinois is out of the woods when it comes to a potential credit downgrade.

"It is not law yet. It is not law," Durkin said. "I don't know how much value the bond houses put into legislation that is facing a veto from the governor."

Sponsoring Rep. Greg Harris, Madigan's top budget negotiator, said during debate that it was time for lawmakers to "rise above" the partisan gridlock of the past several years that is likely to have repercussions for years to come.

"Today, we can change the awful trajectory of the last several years. We can vote. We can do our jobs. We can get it done," Harris said. "We all love this state, and we know we cannot delay any longer."

Just two days earlier, nearly two dozen Republicans had joined Democrats to tentatively approve a spending plan, with Madigan and Durkin telling lawmakers the vote was an expression of good faith as negotiations continued.

State spending has been on autopilot during the impasse, vastly outpacing revenues after the January 2015 expiration of a temporary income tax increase.

The proposal mirrors a plan the Senate passed earlier this year and calls for raising the personal income tax rate from the current 3.75 percent to 4.95 percent, which would generate roughly $4.3 billion. An increase in the corporate income tax rate from 5.25 percent to 7 percent would bring in another $460 million.

Unlike the Senate measure, the tax hike would not be retroactive to Jan. 1 but instead would begin with the Saturday start of the budget year. That change, sought by Republicans, was designed to avoid having people pay even more in income taxes the rest of the year to catch up for the past six months. Also out is an expansion of sales taxes to some services. The tax hike would be permanent, against Rauner's desire to make it temporary to match a temporary property tax freeze he is seeking.

The legislation would also reinstate the research and development tax credit, which would expire in 2022, and increase the earned income tax credit for low-income families. It also ends several corporate tax breaks, including those for companies that operate on the continental shelves or shift production out of state.

After approving the tax increase, House lawmakers quickly signed off on a reworked spending plan that would funnel funds to local schools, social service programs, higher education and other state operations such as the lottery, prisons and road projects. That measure passed 81-34, receiving nine more votes than the tax plan that was needed to cover the cost of the spending.

Under the revised budget blueprint, the state would spend a little more than $36 billion, a roughly $400 million cut from the plan House Democrats first floated. Universities would see cuts of 10 percent instead of the 5 percent in the earlier proposal.

The budget also contains a provision that would prevent monthly school aid payments from going out unless there's also an "evidence based" funding model, an attempt by Democrats to force Rauner to sign a measure they've already passed to revamp how dollars are doled out to schools. Rauner has said that plan amounts to a bailout for troubled Chicago schools.

The Sunday House tax vote capped a tumultuous three days. By Saturday morning, the tone of optimism that had briefly overtaken the Capitol on Friday had started to shift. Madigan announced that no votes would occur on Sunday, which would have given his members some time to go home for a few nights. Durkin accused Madigan of trying to slow momentum.

That dispute sparked angry outbursts on the floor. Rep. Grant Wehrli of Naperville shouted that Madigan was "Speaker Junk," a reference to the anticipated credit rating downgrade to junk status as the state entered a new fiscal year without a budget in place.

Hours later, Madigan reversed course and announced his plans to put the tax plan up for a vote on Sunday, even though it was clear Durkin would not deliver the 30 GOP votes the speaker has asked of him. Democrats said it was time to see who was ready to vote for a tax hike, saying that some Republicans have expressed a desire to break from Rauner and support the plan.

Indeed, Rep. David Harris, R-Arlington Heights, voted in favor of the tax bill, saying Sunday that he was not elected "to preside over the financial destruction of this state."

"How many of our business people have told us they need stability?" Harris said. "This revenue bill gives them that, and it ends some of the horrible dysfunction that has infected our government."

Rep. Reggie Phillips, R-Charleston, whose district is home to Eastern Illinois University, said he credited the state's college tuition grant program for making it possible for him to attend college. He also noted that he is a business owner in Charleston and the financial troubles caused to universities by the state budget impasse have rippled into university towns.

"I'd like to save my university. I'd like to save my town," Phillips said. "And so although it's against some of the principles that I came here for, I am going to vote for this bill."

While Rauner has said he could support a tax hike, his signature comes with a list of conditions.

Rauner is pushing for a property tax freeze in exchange for his approval of an income tax hike. Democrats are open to a four-year freeze, but the governor argues that if a freeze is temporary, the income tax increase should also be temporary. Democrats have opposed that, saying it will lead to more financial problems down the road.

Another holdup centers on Rauner's push to overhaul the state's workers' compensation system. Rauner wants to cut fees doctors get for treating patients, which advocates say will help businesses control costs. Democrats say the fees were slashed several years ago and want tougher oversight of insurance rates, contending the industry hasn't passed along savings.

The Democratic-controlled legislature has yet to meet Rauner's conditions, and the governor blasted them Sunday.

"Illinois families don't deserve to have more of the hard-earned money taken from them when the legislature has done little to restore confidence in government or grow jobs," Rauner said in a statement. "Illinois families deserve more jobs, property tax relief and term limits. But tonight they got more of the same."

Rauner and his Republican allies have also pushed in negotiations to keep any eventual tax hike as low as possible. When House Democrats crafted their tax-hike bill, they kept rates at the level that Senate Republicans had insisted upon when negotiations were taking place in the Senate.

That left some Democrats dissatisfied with the amount of money that would be available to fund programs and services that have been starved of cash for the past two years.

Rep. La Shawn Ford, D-Chicago, said the budget plan was "not a compassionate budget," and was instead a "compromise that's brought on by the threat of a junk bond rating, not by the pain of the people."

mcgarcia@chicagotribune.com

kgeiger@chicagotribune.com

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Madigan's House approves major income tax hike as Republicans break with Rauner - Chicago Tribune