August 24, 2017

Don’t Believe Caller ID

Or the From address on an email.

Got a phone call from 802 760 xxxx the other day. My number is 802 760 yyyy. “A neighbor,” I thought, even though I didn’t recognize the specific number and it had no name associated with it. I answered. It was a scam. Didn’t stay on long enough to know precisely which scam and wasn’t close to revealing any identifying information or sending money in order to free my lottery winnings.

It’s unlikely this call originated in Stowe even though that’s where 802 760 xxxx numbers are. With voice over IP services like Vonage, you can actually buy a number anywhere; we used to have one in the UK so our daughter,who lived there, could call us cheaply. But this wasn’t a number designed to be called. This was a SPOOFED number, a number inserted into the data stream by the computer that was making the call.

In the old days of the hard-wired phone network, the phone company’s switch figured out what number a call came from because it knew which pair of wires the call came in on. That was then; this is now. All bulk calls including legit ones are placed by computers which tell the phone company computer the caller’s phone number. It’s no surprise that computers can be programmed to lie. The new thing is to have the fake phone number have the same area code and even the same exchange as the called number in hope that you’ll pick up and let yourself be scammed.

Similarly it’s easy to create an email which looks like it came from you. Scammers get hold of millions of emails with carelessly many people on the “to:” and “cc:” lists, usually from failure to use “bcc:” properly to hide email addresses.  The scammers create new email, which usually pretend to be from the sender of an innocent email the scammers have possession of to each of the listed recipients of the innocent email.  The subject is something generic like “Hey, look at this” or “wow, made me think of you.” The email either has a toxic attachment or an evil link. Open either at your peril. You can’t believe an email is from a friend just because it says it is. Sometimes these “spearing” emails are sent from an infected computer whose address book is being used; but usually they are just created from carelessly long address lists not put in the BCC field.

I don’t open attachments or follow links in emails unless I know that I know whom the email is coming from. If the email is from my friend, for example, and it has text that says the picture reminds me of you falling out of the sailboat on our last trip and I did fall out of a sailboat, then I assume it’s safe (if maybe not pleasant) to look at the picture. If I’m not sure, I write to the alleged sender FORWARDING the suspicious email and typing the address or entering it from my address book, NEVER, NEVER, NEVER by replying because a fake email will have the reply go back to the scammer, who will then reply “Yes, it’s real,” pretending still to be your friend.

We live in a dangerous cyberworld. Be skeptical and careful.

See CC’ing Will Get Your Friends Speared for how to properly use BCC.

August 22, 2017

Is Medicaid Helping Fuel the Opioid Crisis?

Probably.

According to Express Scripts, which is a large manager of pharmacy benefit plans including Medicaid, “Medicaid members are 10 times more likely to suffer from addiction and substance abuse than the general population.” Unfortunately Express Scripts doesn’t give a source for this statistic and it doesn’t appear in the full text of their report. This sentence may refer to both drug and alcohol abuse and it doesn’t help us untangle cause and effect.

Some people qualify for Medicaid because substance abuse restricts their income.  Almost 25% of 3.1 million Medicaid subscribers whose records were scrutinized in the Express Scripts study had opioid prescriptions in 2015.   Having Medicaid available to pay for pain killers relieves pain which people might otherwise have suffered. But does having Medicaid available encourage opioid abuse?

In an editorial, The Wall Street Journal  says: “Evidence suggests the program may contribute to the epidemic… Overdose deaths per million residents rose twice as fast in the 29 Medicaid expansion states—those that increased eligibility to 138% from 100% of the poverty line—than in the 21 non-expansion states between 2013 and 2015.”  Their argument comes from a statement Senator Ron Johnson (R-WI) made, which doesn’t appear on his website and for which I can’t find a link.

In the statement Johnson quotes a letter he sent to the Inspector General for the Department of Health and Human Services, which I also can’t find online: “it appears that the program has created a perverse incentive for people to use opioids, sell them for large profits and stay hooked.”

If Johnson is right, this is a huge problem. The incentives are easy to understand. If an addict has anything of value, he’ll sell it to feed his habit (except possibly pills which he can take himself). The copay on legally prescribed opiates is far, far less than their street value. If there were no abuse, it would be truly extraordinary. What matters is whether the abuse is significant and is helping fuel the crisis

The WSJ’s only source for this statistic is “a federal Health and Human Services analysis requested by the Senator”. No link to any such study. No study I can find on Google. Because I think the subject is crucially important, I did some research. Age-adjusted opioid deaths by state for 2013 and 2015 can be found in a report from the Centers for Disease Control. I found a list of states which expanded their Medicaid programs here. Note that my source lists 19 states which didn’t expand eligibility while WSJ says 21. Since they didn’t give their list, I can’t reconcile the difference.

Using these sources, I get the same results as the WSJ. The statistical method is somewhat suspect, however, since it averages results from states with different populations. Population adjusted, deaths from opioids increased “only” 59% faster in expansion states.  Statistically, the fact that this correlation exists both state by state and in the aggregate increases the likelihood that it is more than a coincidence  , and so this is not good news.

Another possible reason to discount the statistic as being evidence of cause and effect is that there are demographic differences between the mostly red states which rejected Medicaid expansion and the mostly blue states which implemented it. WSJ tries to address this by comparing states with similar demographics: “Deaths increased twice as much in New Hampshire (108%) and Maryland (44%)—expansion states—than in Maine (55%) and Virginia (22%). Drug fatalities shot up by 41% in Ohio while climbing 3% in non-expansion Wisconsin.”

Here WSJ is cherry-picking to some extent. Vermont is more like Maine than New Hampshire is and Vermont is an expansion state. There was “only” a 6% increase in opioid-related deaths in Vermont from 2013 to 2015; but I can’t find many such exceptions among similar states. There are states like Vermont which did support Medicaid expansion and had relatively low increases: California (5%), Oregon (11%), Arizona (4%); but these are exceptions. Maine is the “no” state with the highest increase; most of the rest of the “no”s had relatively low increases or, in a few cases, decreases.

It looks like there is a statistical correlation between expanding Medicaid eligibility and increases in opioid related death rates. A statistical correlation does NOT prove cause and effect. There is also a possible explanation for cause and effect: the huge difference between the copay on opioids and their street value coupled with the need of addicts for money.

Only 4.1% of Medicaid’s costs are the direct fulfillment of opioid prescriptions according to The Express Scripts study. However, the indirect costs of addiction to Medicaid must be much higher both since addiction itself needs treatment which must be paid for and because addiction leads to diseases and accidents which must be treated. If Medicaid is fueling addiction, then its costs will keep spiraling up.

The cost of addiction to society is huge and growing. Addiction is devastating both to addicts and to their families.

If expanding Medicaid caused drug-abuse to increase significantly, then base Medicaid is also likely fueling the problem, which is actually a crisis. Although nothing above proves that expanded Medicaid causes increased drug abuse, there is clearly enough reason for urgent study. Since Medicaid administration is a state responsibility (with many federal rules), states – including Vermont – ought to both examine the safeguards against over-prescription and resale and do actual forensic investigation of possible abuse including, of course, doctors and pharmacies. Of course, the feds should be looking as well.

Making sure everybody has access to affordable basic health care is a laudable goal. Avoiding the unintended consequence of damaging public health and safety with misspent healthcare dollars is a necessity.

August 17, 2017

American Tears

My nephew Luke’s maternal grandparents are holocaust survivors. On his paternal side we’re descended from refugees fleeing Eastern European pogroms. Luke’s wife, Sokchea, survived the Cambodian genocide. The events in Charlottesville led Sokchea to write this sad and beautiful letter to their baby daughter.

My innocent girl, in a few years, you will learn humanity's saddest lesson. No matter who you are or what you do, there are people who will hate you. They will say it's because of the color of your skin or where your ancestors came from. But it's just because you are different than them.

On that sad day, your dad and I will hold you and we will explain to you that nothing is wrong with you. You are a little girl who is loved by two very different people who found love by embracing their own differences. You don’t look like mommy, because you are unique. You don’t look like daddy, because you are unique.

You will have people ask you "what are you?" You will even have people call you names just because you look different. You’ll be faced with the gawking pupils of white men who may look at you in disgust. Or worse. And then you'll wonder why there are white women who are doing the same.

I write you this today because I saw something that struck me. Today I saw a sign calling out Jews and condemning immigrants to hell. They’re talking about you. They want to burn your Jewish side and desecrate your Cambodian soul. And I kept wondering, “how can they think that about you?” If only they can see your smile. Feel the gentle snuggle of your hugs in the mornings. Laugh at your baby babbles. Or maybe if they saw how you've learned to fake laugh or cry to get your way, would they still carry those signs and chant hatred? I wish more than anything that I can explain to them that you are not evil. You cry, laugh, and bleed just like them and their children.

But in the end - what I really want for you to know is that you are different. And that that difference is what makes this world worth exploring. Worth enjoying. Worth loving. Because if we were all alike - then we might as well live in front of a mirror. When you finally lose your innocence and begin to learn what makes you different - please remember that difference is what created you.

Stay safe, my love.

August 16, 2017

Whataboutism

Trump, Obama, and Naming Evil

Nothing excuses Donald Trump’s failure to immediately denounce Nazis, KKK members, and white separatists in Charlottesville immediately and by name. Even this slime has a right to march and speak; but they have no right to violence.  Moreover, he should have disowned their claim of allegiance to him even before their march turned violent.

While it is probably true that there were also counter-demonstrators spoiling for a fight, blaming them equally for the death that resulted is like excusing 9/11 because some victims may have been anti-Muslim.

Trump is not excused by his predecessor’s inability to say “radical Islam”; Trump correctly criticized Obama for that so presumably understands the consequence of not being able to say evil’s name. Trump is not excused by those on the left who remain deplorably silent in the wake of violent campus protests against free speech.

Nor is Obama’s failure to lay blame for much terrorism on radical Islamists retroactively excused by Trump’s latest offence. Those who won’t defend free speech are moral cowards or would-be censors no matter what Trump does or doesn’t do. Two wrongs don’t make a right.

According to an article by Jeremy Peters in The New York Times:

“There is also a new political term to describe the circular firing squad in which right and left have blamed the other for the country’s degenerating political debate — ‘whataboutism.’”

“What about” excuses nothing.

As a civil (I wish more civil) society, we suffer from both too little and too much name calling. Nazis, fascists on campus, the current government of Venezuela, racists, and radical Islam need to be called out for what they are. Leaders have a responsibility to speak frankly; they also have a responsibility to let us know how they see the world.

However, not everyone who thinks that immigration cost him his job is xenophobic. Some very good people want to see more gun control; some very good people believe that abortion is murder. All proponents of gay marriage are not agents of the devil; all opponents of gay marriage are not deplorables (HRC was against gay marriage before she was for it). Not everyone who marches with a “Black Lives Matters” banner is a would-be cop killer nor is every policeman who shoots someone of a different race a racist murderer.

David Brooks writes (also in the NYTimes):

“…I’m beginning to think the whole depressing spectacle of this moment — the Trump presidency and beyond — is caused by a breakdown of intellectual virtue, a breakdown in America’s ability to face evidence objectively, to pay due respect to reality, to deal with complex and unpleasant truths. The intellectual virtues may seem elitist, but once a country tolerates dishonesty, incuriosity and intellectual laziness, then everything else falls apart.

“The temptation is simply to blast the neo-Nazis, the alt-right, the Trumpkins and the rest for being bigoted, vicious and hate-filled. And some of that is necessary. The boundaries of common decency have to be defined.

“But throughout history the wiser minds have understood that anger and moral posturing are not a good antidote to rage and fanaticism. Competing vitriols only build on each other.”

There is no question these are hard and scary times. We make them worse both when we refuse to name evil AND when we label everyone we disagree with as being evil. Whataboutism excuses nothing.

August 14, 2017

If We’re All the Same, Who Needs Diversity?

“Diversity in schools and workplaces is crucial,” I remember being told, “because people from different ethnicities, places, economic situations and men and women have different points of view, different ways of looking at a problem.” My experience has been that diversity does bring all these benefits and more. Problems and opportunities are best attacked from diverse points of view.

But I have a question: If we’re all the same, then what does diversity mean? Why would it have any benefits?

An engineer at Google named James Damore wrote a memo on a company forum listing some statistical differences between men and women and giving reasonable although not conclusive sources for the differences he cites. He was supporting his argument that part of the reason there are more male programmers at Google than female is that women statistically may not want this job as often as men do. He’s been fired “for perpetuating stereotypes” even though he conscientiously pointed out that statistical differences between groups cannot and should not be used for judging individuals. It has become impermissible to talk about the differences which are one of the main benefits of diversity!

The Orwellian reality is that “diversity” has become a code word for uniformity of results. Somehow every subset of every profession should have a proportion of men and women, different ethnic groups, and different gender identities which exactly matches the population. I think we Jews are under-represented in the NBA just because statistically we are not very tall and don’t jump as well as certain other ethnic groups.

Like James Damore, I have to acknowledge that stereotypes which arise from some combination of statistical differences and prejudice do often prevent individuals from getting the consideration they deserve for jobs (and country club memberships). Like Damore I think this discrimination is wrong. Even more specifically I know that stereotypes and social pressure discourage some girls from pursuing “scientific” subjects and that these girls and society as a whole both lose by this stereotyping. One of my great pleasures as a grandfather is talking science and math with my granddaughters, both of whom have aptitudes for these subjects.

Even more important, though. I have tried to teach my children and grandchildren that nothing is unthinkable. What if less women than men want to be programmers? What if that’s the truth? We could look at the job and ask why it’s unattractive to many women. If the answer is that there’s a men’s club of programmers who make women uncomfortable, that culture should change.

But if the answer, or part of the answer, is that more (remember, we’re talking statistics) men than women are willing to (or want to) work in a job with minimal social interaction, why shouldn’t that choice be honored for those who make it? I’ve been programming for 57 years. Many of the great programmers I know have borderline Aspergers Syndrome. Many more males are diagnosed with Aspergers (and other autisms) than females. My point, and Damore’s, is that there is a spectrum of statistical differences between genders and so expecting all genders be equally represented in each profession is a dumb goal and leads to reverse discrimination and other dumb decisions.

 Individual choice as well as individual aptitude should determine choice of profession.  Opportunity, of course, must be equal; real results will vary.

Before judging Damore one way or the other, please read his paper. It’s interesting and well written.

Also please see an excellent op-ed in the NYTimes by David Brooks: Sundar Pichai Should Resign as Google’s C.E.O.

August 04, 2017

Hospital Competition Would be a Good Thing

Monday I blogged that ACA (aka the Affordable Care Act aka ObamaCare) is an unworkable political compromise between private health care and government run health care in which insurance companies become rent collectors but add no value. I asked “is it time to just give up the pretense and go to single payer?” – certainly something many on the left believe sincerely would be a good thing.

Reader John McClaughry commented:

“Don't cave in to the socialist "solution" - single payer - just because the fascist "solution" - ACA - fell apart. Replace the unconstitutional individual mandate with income tax based recapture of unpaid medical bills, plus capping the deduction for high priced plans, equalizing tax advantages for individuals, expanding HSAs, allowing catastrophic coverage, breaking up regional health care cartels, removing the efficacy requirement for pharmaceutical patents, allowing insurance purchasing groups, and imposing med mal tort reform. That's for openers.”

John’s suggestion that regional medical cartels be broken up is probably the most important.

A free market usually delivers better product at a decreasing cost over time. That’s even happened with energy despite fears of “peak oil” and it’s certainly happened with computers, telecommunications, and transportation. In order for a free market to work, there has to be competition. We business people don’t willingly lower our prices (and profits); we make reductions so our customers don’t desert us for lower-priced competitors. We don’t plow our money back into R&D just because we love to innovate; we make that investment because we’ll be out of business if a competitor has either a better mousetrap or one that costs less to make.

In much of the country including Vermont competition between hospitals is deliberately suppressed because of the socialist misconception that prices are lowest without the “cost” of over-capacity. Hospitals must get a Certificate of Public Need (CPG) in order to make an investment. They won’t get the CPG if a nearby hospital can demonstrate it already has capacity which will be duplicated. The CPG process assures no competition or pressure to lower cost and prices develops. In theory hospital rates are then regulated to make sure monopolies aren’t exploited. What really happens is that, without fear of competition, hospitals layer on costs such as high pay for doctors and administrators (but not nurses) or overelaborate facilities, which then justify higher prices.

In the competitive world, prices only go down if there is over-capacity. If my competitor and I are running our factories flat out, we won’t reduce prices. But we will add capacity (or someone else will). Pretty soon, as much as we don’t want to, we’re cutting prices to compete. If want to survive, we’re also desperately investing and innovating to distinguish our product and reduce the cost of production. Our customers win.

If there’s competition, some hospitals will fail; that’s a fact. Once airfares became competitive, some airlines failed (and survivors bought their assets at bankruptcy sales). Some of the hospitals which will fail will be “non-profits”. A socialist would say non-profits can offer lower prices because there are no investors demanding a return. Where that’s true, the non-profits will be survivors. If not, they deserve to fail – and should so that more efficient competitors can take their place.

If there’s competition, hospitals will be tempted to cut corners. That’s true and there are expenses we want them to trim. But what about safety? That’s what regulation is for. Airlines can cut costs (and prices) by jamming us in like sardines in the cheap seats; but they can’t put more people on a plane than can be safely evacuated. They can’t skip maintenance. Competitive hospitals will still have to be regulated, just not as much as they are now.

Of course competition is only effective where the consumers care about cost. That’s why McClaughry also suggests HSAs, available catastrophe-only plans, and income tax recapture of unpaid bills.

See also:

A For-Profit Surgical Center is a Good Idea for Vermont

Nice Business To Be In

Freedom, Responsibility, and Preexisting Conditions

Time to Face the Health Care Facts

 

 

August 03, 2017

Arlo by Night

What could be worse than a raccoon in the garden?

First Arlo, my DIY home video camera, discovered a groundhog in Mary's vegetable garden which is being raided faster than leaves can grow. While we were discussing groundhog-elimination strategies, Arlo made another discovery, this one using night vision.

 

In the end the raccoon climbs a ladder-like structure we shouldn't have left there to get to the raspberries.

So what could be worse? It only took a day to find out,

 

That's pretty bad and that was going to be my blog for the day... until a nice lady rear-ended me in traffic. Not my day.

Could be much worse, though. Only bent metal and plastic - and missing raspberries and grapes.

 

July 31, 2017

Nice Business To Be In

You’re in a business where the government requires Americans to buy your product. You’re only allowed to sell the blue-ribbon version of the product; you can’t legally sell an economy version. Many people can’t afford your product at the price you offer it; but that’s not a problem because the government will subsidize their purchase or just compensate you for selling at a “loss”. Competition is all but ruled out by laws which don’t allow a version of your product to be sold across state lines. Industry profits are setting records. What business are you in?

Health insurance, of course.

During last week’s fruitless debate on who pays for health care, Republicans threatened to repeal the individual mandate, the requirement that everybody buy or be offered health insurance. Not surprisingly the health insurance lobbyists were against letting people choose whether or not to buy their product. They pointed out, correctly, that many people wouldn’t buy at the prices they are charging. In Washington scorekeeping, people who choose not to buy insurance are people who will “lose their insurance coverage”.

Even worse, as the lobbyists pointed out, the people who would refuse to buy are young, healthy people who are very profitable. With the most profitable customers gone, rates would have to be even higher for everybody else. Unless Congress raised subsidies even higher, insurance as we’ve known it since the passage of the Affordable Care Act (aka ACA aka ObamaCare) would collapse. It’s hard to be sympathetic toward the insurance companies, which would have been hung in a noose of their own devising – costs going out of control because they can only offer plans no one can afford including coverage for pre-existing and politically expedient conditions and customers being unwilling and/or unable to buy. Strangely anti-corporate Sen. Elizabeth Warren was very concerned about the fate of the insurance companies. She quoted their dire predictions and neglected the attack I would have expected on their profits. Bernie Sanders lost no opportunity to criticize the Republican plan but was, at least in what I’ve read, uncharacteristically silent about profits. Warren and Sanders aren’t good long term allies for the insurance companies, however. They are honest that they want “single payer” health care. If we had that, insurance companies would be out of the loop entirely except perhaps for an opportunity to sell policies providing superior care to people with the money and willingness to buy them.

Although the ACA was passed with no Republican votes (sound familiar?), it was still a compromise between centrist Democrats who knew people wouldn’t like the mandatory coverage and weren’t ready to scrap private insurance and those who looked admiringly at government run and paid healthcare systems in much of the rest of the world.

 ACA has proved to be an unworkable compromise with some of the worst aspects of both public and private health; it’s a disaster financially even though less hospital bills go unpaid by patients. There hasn’t yet been a large-scale study showing improved health outcomes even though people who know their visits will be paid for are going to the doctor more. Costs are spiraling out of control. In my opinion keeping the private insurers in the loop has done nothing but pile on cost and complexity. Private solutions are beneficial when there is competition and a choice of both suppliers and product.  In many markets there are now one or only two providers; products must be gold-plated by government fiat.

Like many benefit programs, this one has proven to be a barbed hook. People are being subsidized by their own tax dollars (with a share subtracted for administration and insurance companies). They have no faith that they’ll be better off personally if cost of the “benefit” is done away with – and some won’t be. Even threatening to repeal the initially-hated personal mandate can’t pass Congress because the ACA (as well as insurance companies) will collapse without it.

So is it time to just give up the pretense and go to single payer? I think that would be a better alternative than trying to maintain the public-private monstrosity called ACA. I would prefer a truly competitive market both for health care insurance and for providing health care (with subsidies for the indigent as we do with food, fuel, and much else). Right now it doesn’t seem we have the political leadership to buck the insurance industry and get us either back to competition or to a government-run (ouch) system with no role for insurers who aren’t providing value.

Just to end on a happier note: Trump has tweeted a threat to make Congresspeople and their staffs buy their own health insurance on the exchanges. The ACA actually requires this but the Obama administration granted a waiver partially based on the fiction that each Congressional office is a small business with less than 50 employees on the average. That which can be waived can be unwaived. Might focus the congressional minds.

 

See also:

What if The Senate Really Debated Healthcare?

Freedom, Responsibility, and Preexisting Conditions

 

July 28, 2017

Arlo Captures Critter

At least on video.

I bought the basic wires-free version of Arlo as an experiment in DIY home security and am trying it in parallel with our traditional system. The first task we gave Arlo was to identify the critter who ransacks Mary's vegetable garden. It's taken awhile but finally Arlo did it. I thought it was rabbits; Mary bet on groundhogs. See the video for the winner

When first installed, Arlo gave lots of false alarms. The alerts can be received on your computer and/or smartphone. Birds were the most frequent cause. So we pointed him at a mass of critter-snack on the ground. Two days later, voila!

Note that you only see the critter leaving. This is because there is a delay between when motion is first sensed and when recording begins. We may have missed the critter a few times because of this so I tried turning up the sensitivity from 80% to 99%. Too many false alarms so had to turn it back down. According to marketing material Arlo Pro (more expensive) responds to motion almost immediately. You can mix and match so I'll probably put a Pro on critter duty and use the old camera for slow people.

 

See also:

Arlo: DIY Home Security

Alexa: The End of a Great Relationship

July 27, 2017

What if The Senate Really Debated Healthcare?

They do have an opportunity.

Thanks to John McCain’s typical bravery, the Senate has taken up the bill passed by the House and IS technically debating healthcare. This debate is a good thing. Who pays for healthcare (which is what this “debate” is actually about) is obviously an important issue. It certainly wasn’t solved for all time by the Democrat’s partisan imposition of ObamaCare; it won’t be solved by rolling the clock back to preObamaCare. Congress is supposed to debate before making policy. The debate is open to both Republicans and Democrats. It’s a slim, slim hope but maybe something good will come from this discussion.

The alternative would be no discussion at all. Many Senators on both sides of the aisle would have preferred no debate because they would have been spared from having to create a record of their votes on amendments. For some reason most of the “resistance” is also against having a debate in the Senate even to the point of vilifying McCain for his vote to allow debate. Frankly, I don’t get it. You’re against an imperial presidency (so am I) but you don’t want the legislature to do the job we elected them to do. Doesn’t compute.

Yes, I’m being a Pollyanna; but there is an opportunity for the actual bipartisan compromise and legislation John McCain pleaded for in his speech. Whether this happens or not is up to both Republicans and Democrats. For example, a Democrat can offer an amendment to the House Bill which solves some of the obvious problems with ObamaCare (like spending being on an unsustainable growth path) while preserving some of its benefits. Republicans might vote for that, especially if the Senate can avoid debating whether it is fixing or replacing ObamaCare and just concentrate on what affects people. A Republican can propose a phasedown of the absurdity of Medicaid with absolutely no limits while providing some funding so the exchanges can function with certainty. Will all Democrats vote against that? I hope not.

If anything passes the Senate, it’s got to go to committee with the House and be accepted there in some form. Tough problem but all House members are up for reelection next year. If a bill passes the House and Senate, it still needs a Presidential signature. I’m the last person to think Trump is predictable; but good chance he’d like to claim a victory (which is NOT a reason NOT to pass a bill).

The reality is that the status quo is not sustainable. Democrats know that the exchanges will simply implode without more funding and that funding isn’t going to happen without Republican votes. Republicans know now (if they didn’t before) that they will be blamed if healthcare funding collapses. Perfection won’t happen; progress can.

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