Jul 17

Subdural Hematoma

Essentially it’s a bruise between the skull and the membrane that surrounds the brain. If it’s not drained and the pressure on the brain relieved… well, it will probably kill you.

But not to worry, Doctors have been treating these for thousands of years by drilling a hole in your head (Trepanning) to let out the demons (seriously, that’s what they thought because of the psychological symptoms) and if you avoided infection and they drilled in the right place you definitely had a very slim chance of surviving (we know this because of archeological evidence of the distinctive markings of the procedure and bone regrowth around the surgical site which indicates several years of post operative survival).

Today of course modern Medical science knows a good deal more (especially about infections) and because of the miracles of imaging we almost always drill in the right place (some early Doctors took 2 or 3 tries), but this is not a trivial event. It’s Brain Surgery Jim.

Nor is the reported size of the blood clot insignificant, 5 centimeters is just about 2 inches, almost the distance between your eyes. After the job is done they pound a Titanium plate in your head (really, they drill more holes and pin it in) and then you’re good to go. Maybe.

I’m not sure I’d be full of piss and vinegar if that happened to me, though John “Wet Start” McCain has the advantage of youth (he’s only 80, I’m over half again as old) and while 2 weeks have been added to the calendar by Mitch McConnell in a hopefully vain attempt to force Trumpcare through the Senate it’s unlikely McCain will be turning cartwheels on his way to the floor for the vote.

If he’s a yes vote at all, Gentleman Johnny was sounding pretty squiffy before they shoved him in the back of the ambulance, but that would be the demons talking of course.

We’ll have to wait until tomorrow for the CBO to tell us how bad it is (hint- really, really bad), but the question is, “why the fealty to a policy that is nearly universally despised?”

The Disturbing Process Behind Trumpcare
by Norm Ornstein, The Atlantic
7/17/17

(L)et’s look at BCRA. It started, of course, with McConnell bypassing the committees that deal with health policy, both Finance and Health, Education, Pensions, and Labor (HELP) by handpicking 13 Republican senators—all middle-aged and elderly white men—to work in complete privacy to draft the bill. Besides women like Senators Susan Collins and Lisa Murkowski, McConnell also left off Senator Bill Cassidy of Louisiana, a physician with deeper knowledge of health policy than nearly all of the 13 chosen. The gang of 13 kept their vow of omerta, leaving even their Republican colleagues at sea during their sessions. And of course, McConnell brushed aside peremptorily any notion that Democrats would be brought into deliberations, or consulted.

Nor were the groups representing those on the front lines of health policy and delivery, including doctors, hospitals, insurers, nurses, those with debilitating diseases, and more, consulted or included. One of the more striking, and embarrassing, moments came when McConnell—who had overcome polio as a child—refused to meet with the March of Dimes, the non-profit founded in the New Deal era to combat the disease.

The bill that emerged was, of course, a catastrophe. It was not a carefully constructed health-policy bill, but basically a vehicle to give ginormous tax cuts to the wealthiest among us, financed by almost $800 billion in cuts from Medicaid, while also adding immensely to the health-care costs of poor and older Americans. The CBO score was devastating. And despite repeated vows to vote before the July 4 recess, McConnell had to take the bill back to the drawing board. Over the recess, we saw another remarkable phenomenon. Senators who went back home, ostensibly to meet and communicate with their constituents, instead mostly behaved as if they were in witness protection programs—doing everything they could to avoid town meetings or any gatherings with voters, or in some cases to hold meetings only with a pre-selected group to keep out those who would be hurt by the health bill.

The next iteration of the McConnell bill made a concession to Senator Ted Cruz to nail down votes from the radical members of the Senate GOP that health experts said would blow up insurance markets. It pared down some of the tax cuts, primarily to give McConnell a $200 billion-plus slush fund to lure recalcitrant Republican senators; he promptly threw in $42 billion more for opioid treatment to corral Senators Rob Portman of Ohio and Shelly Moore Capito of West Virginia, and tossed billions more to Alaska to nail down Senator Lisa Murkowski.

But despite adding $172 billion to stabilize insurance markets, the bill kept all the provisions to blow up Medicaid, dealing victims of the opioid disaster a much larger blow than the additional $42 billion, continued to defund Planned Parenthood, and drew sustained condemnation for every major health industry group, every major health policy analyst, a slew of governors including Republicans like John Kasich of Ohio and Brian Sandoval of Nevada. And the approval of the bill with the public stood at 38 percent in a Kaiser poll, lower than any piece of significant legislation I can ever recall.

Compounding all this, McConnell was intent on moving the bill before a new CBO score, even pushing to substitute a number from the Department of Health and Human Services. Along the way, to build support among wavering senators, administration officials led by HHS Secretary Price and Vice President Pence offered reassurances and statements that were simply false—so much so that Republican Ohio Governor John Kasich actually called out his own vice president.

By every past standard, and every logical standard of behavior in a representative democracy, this bill should be dead. It is not. Why not?

Republicans have no easy way out of a box canyon on health policy of their own making.

The ACA was fundamentally built on the Republican alternative to Clintoncare in 1993-94, as crafted by Charles Grassley, Orrin Hatch, the late John Chafee and the former Senator David Durenberger. Their alternative had competition for private insurers on regulated exchanges, and an individual mandate to buy insurance to broaden the risk pool and get rid of the burden of pre-existing conditions. When Republicans in 2009 decided not to cooperate with Democrats in Congress, but to unite in full-throated opposition to any plan that emerged, and then to work actively to delegitimize whatever passed, they created a big dilemma. Call Obamacare the worst thing since slavery, as Ben Carson did, vote over and over to repeal it root and branch—and you can’t then turn around and adopt its framework. That left no workable framework.

Of course there is a workable alternative: join with Democrats and fix the problems in Obamacare, stabilizing insurance markets, expanding Medicaid in the states that have failed to do so, finding ways to make the individual mandate work better to expand the risk pool more. But after a decade of success inflaming tribal warfare, that is not a path McConnell and Ryan are willing to take.

Republicans had no real interest in actually fixing the health-care system. This bill is far more a delivery system for tax cuts for the rich, paid for by cutting Medicaid.

Those tax cuts are the number one priority for conservatives in and out of Congress. But this could become a twofer. Conservatives have hated Medicaid ever since it was created in 1965. As Medicaid expanded to become the vehicle to pay for long-term care for the elderly along with care for the disabled and mentally ill, it became a huge government program. When Medicaid expansion became a core vehicle in Obamacare for giving health insurance to the poor, it became larger yet. So Republicans in Congress seized the moment to do something they have been unable to do in more than five decades—cut the program dramatically and shift the burden for the cuts largely to states. Doing so meant freeing up hundreds of billions of dollars that could then be used to pay for the first wave of deep tax cuts aimed especially at the richest among us. Indeed, the first BCRA iteration provided a boon for the 400 richest Americans that was large enough to pay for the Medicaid benefits of 725,000 Americans.

The tax-cut drive, however, was made much more complicated by budget rules. To get big tax cuts, Republicans have to avoid a Senate filibuster by Democrats; that means finding a vehicle that can bypass the 60-vote hurdle. Enter budget reconciliation. But reconciliation poses major hurdles to passing things that blow up deficits and debt. And reconciliation must be preceded by a budget resolution with instructions on what can be reconciled. ACA repeal was included in the budget last year—but not separate tax cuts. Those will require a new budget resolution and a second reconciliation bill. If Republicans can get a big part of their tax cuts done now, and paid for, it will make the second tax-cut bill much easier to craft within the rules.

Republicans don’t fear the backlash from a bill that will hurt lots of people, including their own voters.

Some think the simple fact of acting, and getting a policy victory, will help. Others may actually believe that the bill will work—hard as that is to believe. But the ideological view that cutting government magically brings freedom and prosperity and good health is strong among many Republicans in Congress. Nonetheless, the more rational or pragmatic ones know that this bill will hurt a lot of people, with a heavier concentration among the white working-class voters that are a mainstay of the current GOP. So why no fear? For one thing, the large tax cuts for the ultra-rich may guarantee that the web of billionaires contributing huge sums to 501(c)4s and other entities to help elect Republicans will double down. In the special election in Georgia’s sixth district, Democrat Jon Ossoff collected a mind-boggling sum for his campaign from small donors; if Karen Handel had not been able to match that with a flood of independent ads financed by big money, we might have seen a different outcome.

For another, with Justice Neil Gorsuch on the Supreme Court instead of Merrick Garland, states under GOP control and possibly even Congress will pass more and more draconian voter suppression laws (New Hampshire just joined the ranks) that will get a much more favorable treatment down the road. They will be aided by Trump’s outrageous new commission on voting, co-chaired by the king of voter suppression, Kris Kobach and including an all-star list of other voter suppressors, which is already intimidating voters. Money and voter suppression laws could well enable Republicans, even if this disaster of a bill passes, to keep control of both houses at least until 2020—and during that time, they can do even more to tilt the campaign finance system and narrow the electorate to their advantage.

Put it all together, and what emerges is a truly disturbing picture of a failed legislative process built on a deep distortion of representative democracy. A thoroughly partisan, ill-conceived and ill-considered bill, slapped together without the input of experts or stakeholders, done not to improve the health care system but to aid plutocrats, crafted in a fashion that will hurt millions and millions of Americans, by lawmakers doing whatever they can to avoid interacting with their own constituents. Dismaying, even despicable. And worse is that so many senators who should know better, and many who do know better, will actually vote for the monstrosity—and give this illegitimate process their imprimatur.

This Bill should already be dead and while I keep hearing hopeful noises that delay works to our advantage I’m not at all sure it’s so.

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  1. Vent Hole

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