In which JD Vance fleshes out Trump's "concept of a plan" for healthcare

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JD Vance is catching a lot of flak for seconding Trump’s debate assertion that when “Obamacare was collapsing…[it wasn’t], he chose to build upon it and make it better” — and for claiming that Trump currently has a healthcare reform plan.

While Vance’s claims are misleading, and the “concepts of a plan” he went on to sketch out would harm the ACA marketplace, not help it, it is in fact true that after Republicans’ drive to substantially repeal the ACA collapsed in 2017, the Trump administration did implement measures that according to conservative precepts would improve markets. A second Trump administration would probably more or less repeat those measures and extend them - -if it fell short of substantially repealing the ACA.

Here is part of what Vance sketched out (via my own near-verbatim transcript):

President Trump’s healthcare plan is actually quite straightforward: you want to make sure pre-existing conditions are covered, make sure people have access to the doctors they need…you also want to implement some deregulatory agenda so people can pick a health plan that suits them. Think: a young American doesn’t have the same health needs as a 65 year-old American. A 65 year-old American in good health has much different healthcare needs than a 65 year old with a chronic condition. We want to make sure everyone is covered, but the best way to do that is to actually promote some more choice in our healthcare system and not have a one-size fits all approach that puts a lot of people into the same insurance pools, the same risk pools — that actually makes it harder for people to make the right choice for their families….

He [Trump] of course has a plan for how to fix American healthcare, but a lot of it goes down to deregulating the insurance markets so that people can choose a plan that actually makes sense for them.

Various healthcare experts, including KFF’s Larry Levitt, have taken this as a proposal to establish high risk pools — a favorite conservative nostrum with a long history of being underfunded and inaccessible to those who need them. That may be true in a sense. But based on the past Trump administration actions that Vance alludes to, the “high risk pool” may be the current ACA marketplace itself — after a second Trump administration gets through with it.

---

The Trump administration’s major initiative to “build on” the ACA marketplace after repeal failed was to stand up (by administrative rule in 2018) a parallel market of medically underwritten, lightly regulated plans by extending the allowable duration of already-existing so-called “short-term, limited duration plans” (STLD) to up to one year, renewable twice. The Obama administration had limited STLD duration to three months, though not until 2016. In combination with the Republican Congress’s zeroing out of the tax penalty for failing to obtain ACA-compliant insurance, the STLD market was an alternative for people who were priced out of the regulated ACA marketplace — as several million people were before the Biden administration removed the income cap on subsidy eligibility via the American Rescue Plan Act (ARPA) in March 2021. (The ARPA subsidy enhancements were temporary, and extended by the Inflation Reduction Act only through 2025.)

STLD plans can refuse access to people with pre-existing conditions or exclude coverage for the condition. They do not have to cover the ACA’s Essential Health Benefits and generally offer very limited prescription drug coverage, if any, and no substance abuse coverage. They are not subject to the ACA requirement to spend at least 80% of premiums on members’ medical bills (and on a few allowed other expenses) and have been reported to spend as little as 45% of premiums on claims. They do not have to offer a provider network and can pay providers what they deem appropriate, exposing enrollees to balance billing. They do not have to provide an annual out-of-pocket cost cap on covered benefits, though some do. They are much like the plans offered in the pre-ACA individual market.

[n.b. the rest of this post more or less remixes my discussion of the STLD market under the last subhead in this post].

Taking the short term and limited duration out of Short Term Limited Duration insurance was a bad solution to a real problem. The Affordable Care Act promised to make adequate, affordable insurance available to all, via public program or private insurance, but under-subsidization meant that the program fell far short of that promise. Most acutely, the income cap on subsidy eligibility (400% of the Federal Poverty Level) ensured that minimum essential coverage was unaffordable to several million people (as the ACA’s guaranteed issue and EHB requirements had raised the price of coverage). In the most extreme case, a pair of 64 year-olds in Nebraska with an income of $67,000 — just over the 400% FPL threshold in 2018— would have to pay an average of $2,667 per month for the lowest-cost bronze plan available. That year, the average bronze plan single-person deductible was $6,002. More broadly, in August 2015 Urban Institute scholars Linda Blumberg and John Holahan calculated, in a proposal for ACA reform, that marketplace enrollees in the 400-500% FPL range (just over the subsidy eligibility threshold) would pay 18% of income for marketplace premiums and out-of-pocket costs at the median and 25% of income at the 90th percentile.

The expanded STLD plan market at least potentially degraded ACA marketplace risk pools while saddling some people with illusory insurance that failed them when they needed it, as several news accounts related. Still, not all STLD plans were (or are) terrible. Some have extensive provider networks and out-of-pocket cost caps. For some customers not shut out of coverage for a serious pre-existing condition, they offered better-than-nothing coverage at a price well below ACA marketplace coverage — though ARPA’s removal of the income cap on subsidy eligibility vastly reduced the pool of people for whom this is true (and letting the ARPA subsidy boosts expire is therefore essential to remaking the market along these lines). From a healthcare conservative’s perspective, Trump could be said to have “built on” the ACA — though his measures plainly were designed to undermine the ACA-compliant individual market.

To further stimulate the parallel market, CMS administrator Seema Verma proposed loosening the requirements for state “innovation waiver” proposals authorized under ACA Section 1332 and issued a set of “waiver concepts” inviting states to propose schemes that would enable ACA-noncompliant plans to access federal premium subsidies. Georgia was the only state to partially accept the invitation, filing a waiver proposal in late 2020 that, along with establishing a reinsurance program, would eliminate a centralized state-sponsored exchange, establish a “copper” plan level with an actuarial value below the minimum required by the ACA statute, and, in one early iteration, allow plans that did not include all EHBs to be paid for with federal subsidies (that provision was cut from the submitted waiver, as it violates the ACA statute too plainly even for Trump-appointed administrators). While the Trump administration approved the waiver in November 2020, the Biden administration suspended approval of all but the reinsurance program, pending redesign. Georgia has now received CMS approval to open a conventional state-based marketplace, albeit the first to enable Enhanced Direct Enrollment on commercial sites. (Promotion of EDE, which facilitates fast work by brokers, is another Trump administration initiative that can be said to have “built on” the ACA, and was continued by the Biden administration — though EDE has recently proved double-edged, enabling large-scale agent/broker fraud. Weirdly, the pending Georgia exchange has certified for use in November two EDE entities suspended by CMS in August for suspected security breaches and participation in enrollment fraud.)

Failing legislative repeal and “replacement” of the ACA along the lines of the Frankenstein-monster Republican bills of 2017 (the AHCA, the BCRA, and Graham-Cassidy) a second Trump administration could be expected to push Verma’s waiver concepts in directions that clearly violate the ACA statute, e.g. by allowing federal subsidies to fund medically underwritten plans or plans that do not include all of the ACA’s required Essential Health Benefits. On this as on all other fronts, a second Trump administration would likely be less constrained by law than the first one. In combination with sunsetting the ARPA enhanced subsidies, such measures could indeed convert the ACA-compliant into a high risk pool, as former Obama-era acting CMS administrator Andy Slavitt warned that Trump’s STLD market would do. That is, with medically underwritten plans eligible for subsidies, only those with pre-existing conditions might choose ACA-compliant that don’t discriminate on the basis of health.

Takeup of STLD plans appears to have been far more limited than some market watchers feared or CBO predicted in the wake of the Trump rule. That’s in part because more than half of states either limited STLD terms on their own (as the Trump administration rule permitted) or banned them altogether. The Biden administration removed most (not all) of the demand for STLD plans as a full-year coverage option via the ARPA subsidy enhancements, and retracted the Trump administration’s extension of allowable STLD plan terms, limiting them once again to three months. A recent Commonwealth Fund analysis concluded:

A modest number of people — no more than one-fifth of the 1.5 million the CBO projected — are likely to have enrolled in STLDI plans that became available after the Trump administration’s regulatory change. This enrollment mainly appears to have displaced marketplace coverage. There is no evidence that the broader availability of STLDI plans had any meaningful effect on nongroup coverage in general or on uninsurance.

If the ARPA subsidy enhancements are allowed to sunset, however, and the Trump administration encourages state initiatives like Georgia’s, effectively eliminating government-sanctioned exchanges and allowing subsidies for ACA-noncompliant plans, Trump’s “concept of a plan” may take chaotic but recognizable shape.

I should add, too, that fraught and important as political combat over the shape of the individual market for health insurance was, is, and will be, to a large extent this fifteen-year battle obscures the core battleground of ACA-related healthcare policy: funding and eligibility for Medicaid. Virtually all formal Republican healthcare proposals, from ACA repeal bills to Republican Study Group plans, Project 2025, and Trump administration budgets, include massive cuts to Medicaid, including rollback of the ACA expansion of Medicaid eligibility. The ACA extended Medicaid eligibility to all citizens and most legally present noncitiizens with incomes up to 138% of the Federal Poverty Level — an expansion rendered optional for states by the Supreme Court in 2012 and currently implemented by 40 states plus D.C. At most recent count (December 2023), some 22 million Medicaid enrollees are rendered eligible by ACA eligibility criteria. Proposed Republican cuts to Medicaid invariably go far beyond repeal of the ACA eligibility expansion by converting Medicaid funding to block grants or imposing per capita caps on funding, plans. CBO forecast in 2017 that the BCRA, the Senate ACA repeal bill, would cut Medicaid funding compared to then-current law by 26% in the first ten years and 35% in the next ten ($2.1 trillion by CRFB’s estimate). Those plans are core to the Republican agenda, and would do more damage than any disfigurement of the individual market.

Ultimately, the pre-existing condition that matters most, and is shared by most Americans (and indeed most humans), is inability to pay full price for health insurance. For most Americans under age 65, an employer pays the bulk of the premium, typically about three quarters of family coverage or five sixths of individual coverage. In the ACA marketplace, the government fulfills that role for more than 90% of enrollees, paying an average of more than 80% of the premium. In Medicaid, federal and state government pay the entire premium. Republicans want to kick 15-20 million people off Medicaid, sharply cut subsidies in the individual market, and alleviate the cost of those individual market cuts for some by subsidizing medically underwritten, lightly regulated insurance. That’s their concept. That’s their plan.

UPDATE, 9/20/24: As noted at the top, most interpreters of Vance’s comments assume he was proposing the kind of high risk pools that existed — and generally failed to make adequate affordable coverage available to those who needed them — before the ACA. Further Vance comments on Sept. 18 , in which he alluded to allowing “people with similar health situations to be in the same risk pools,” reinforce that impression. Today, however, a statement the Vance campaign provided to the Washington Post’s Dan Diamond and Meryl Kornfield, make me think that I was on the right track in this post:

“Senator Vance was simply talking about the significant improvements President Trump made to the Affordable Care Act through his deregulatory approach, which aimed to bring down the cost of premiums while ensuring coverage for pre-existing conditions,” spokesman William Martin wrote in a text message.

Again, the full context was defending Trump’s claim that after ACA repeal failed, he “built on” the program — as well as that he has “concepts of a plan” for new reform.

See also the next post: Did Trumpcare really insure Vance family members for the first time?

UPDATE, 9/23/24: A fresh look at Seema Verma’s waiver concepts for states (11/29/18) reinforces my sense that these concepts plus a revived full-term STLD market (or equivalent) is Vance’s “concept of a plan.” The waivers concepts (abbreviated below) include:

• Account-Based Subsidies: Under this waiver concept, a state can direct public subsidies into a defined-contribution, consumer-directed account that an individual uses to pay for health insurance premiums or other health care expenses [e.g., for a medically underwritten alternative to ACA-compliant plans]

• State-Specific Premium Assistance: A state may design a subsidy structure that meets the unique needs of its population in order to provide more affordable health care options to a wider range of individuals, attract more

  young and healthy consumers into their market, or to address structural issues that create perverse incentives, such as the subsidy cliff.

• Adjusted Plan Options: Under this waiver concept, states would be able to provide financial assistance for different types of health insurance plans, including non-Qualified Health Plans, potentially increasing consumer choice and making coverage more affordable for individuals.

• Risk Stabilization Strategies: To address risk associated with individuals with high health care costs, this waiver concept gives states more flexibility to implement reinsurance programs or high-risk pools. For example, a state can implement a state-operated reinsurance program or high-risk pool by waiving the single risk pool requirement under section 1312(c)(1) of the ACA.

So, high risk pools per se are one option, while drawing the young and healthy voluntarily out of the ACA marketplace, rendering the marketplace a high-risk pool of sorts, is another. These concepts really fit Vance’s sketch to a T

Hey America, let's go through the Obamagate

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Trump, displeased by U.S. law enforcement and intelligence agencies' investigations of the criminals and traitors who staffed his 2016 campaign and early administration, is deploying Barr (and his own deranged rhetoric) to smear and criminalize those efforts and tie them to the past administration under the rubric of "Obamagate."

In Trump parlance, "Obamagate" is a mass of trumped-up charges and projections advancing the fiction that Obama, like Trump himself, deployed law enforcement and intelligence to pursue his personal enemies and protect his personal friends. Obamagate is a moral looking glass through which Trump's face is imposed on Obama's.

I'll give Trump this: The term does have a certain resonance. Would that this country could pass through an equally fantastic Obamagate to various norms and benefits we took for granted when Obama was president.

If only we could..

• Pass through an Obamagate to a time when the president put the national interest above his personal interests, and worked as hard to advance prosperity and opportunity in states run by his political rivals as in states run by his political allies.

Privatizing Medicare: Paul Ryan's soul goes marching on

ICYM the prior post on Trump's executive order aiming to advance the privatization of Medicare on multiple fronts, I've had the chance to refine it twice, on BlueWaveNJ and at medicareresources.org (hence the blogging drought here).

The short version (from the medicareresources.org post):

Issued on October 3, Trump’s order instructs the Secretary of Health and Human Services (HHS) to take steps aiming to

• “Voucherize” Medicare in the manner proposed by Paul Ryan – that is, let private Medicare Advantage plans set prices for traditional Medicare, rather than vice versa as at present.

• Create a private insurance market outside of Medicare for wealthy seniors that would likely lure doctors away from participation in Medicare.

• Subject Medicare enrollees to the joys of “balance billing” – getting billed by providers for amount in excess of their normal share of the Medicare bill.

Trump's CSR cutoff is still reverberating

There is a kind of settled wisdom by now about the effects of Trump's cutoff of federal reimbursement of insurers for the Cost Sharing Reduction (CSR) subsidies they are obligated to provide to qualifying low-income enrollees in the ACA marketplace.

The story line: 1)states and insurers reacted swiftly and rationally by "silver loading" (explained below); 2) confining silver loading (explained in note at bottom) to on-exchange plans holds the unsubsidized harmless from the pricing in of CSR; 3) virtually all states and insurers will arrive at this solution; so silver-loaded CSR is now baked in, benefiting subsidized enrollees and not harming the unsubsidized. 4) Only further administration sabotage -- banning silver loading -- can disrupt this new normal.

The story line is essentially on target. About two million subsidized enrollees took advantage of bronze/gold discounts in 2018. The availability of those discounts probably helped offset other shocks to the system -- a halved enrollment period, radical cuts in outreach and enrollment assistance; insurer uncertainty as Republicans came within a whisker of repealing the core programs of the ACA.  Going forward, CBO estimates that silver loading will boost enrollment by 2-3 million per year (though I'm pretty sure the boost was in the low-to-mid hundred thousands in 2018, when silver premiums rose almost twice as much as gold and bronze). Further, some 70% of enrollees were in states where silver loading was concentrated on-exchange.

But that's not the whole story. Trump's threat to cut off CSR payments loomed for nine months before he pulled the trigger and was a major component of the general uncertainty insurers faced while filing rate proposals or deciding whether to participate in the marketplace. The effects of that uncertainty on premiums is, I suspect, not entirely captured by the calculated priced-in cost of CSR.  And now, here cometh the Congressional Budget Office to remind us that sudden policy changes have lingering effects, and the CSR shakeout isn't fully shaken out.

Getting rid of Trump on the cheap

Shortly after Trump won the presidency, David Frum warned that the gravest danger to American democracy was the likelihood that Republicans in Congress would refuse to hold him accountable and would go along with his multi-front assaults on core American institutions and norms. Ever since then, I've thought that a stupid Trump move that triggers a recession or economic crisis might be the one thing that would induce Republicans to drop him -- "like a hot rock," as McConnell once falsely promised to do prior to Trump's nomination. If so, a recession would be the cheapest way we'd likely find to shake off the various mortal and merely grave dangers Trump poses. Trump's tariffs have markets gyrating and shaking; they could trigger this scenario

Wishes can be calibrated only in superstitious prayer. So much could go wrong with this scenario. Trade war could trigger hot war. Trade war could start, and Trump could set off an unrelated hot war. Trade war could lead to global depression. Republicans could stick with Trump no matter what he does. Various crises could trigger other extreme reactions in Trump -- moves to shut down media or criminalize/jail adversaries of various types. And of course, trade war may not happen -- China may give Trump a fig leaf while cleaning his clock in negotiations.

Nonetheless, a tightrope walk of fortune -- a Trump-triggered financial crisis (hopefully of the short and mild variety), followed by a Republican loss of one or both houses of Congress, followed by Republican acquiescence in various Congressional moves to rein Trump in, up to and including impeachment -- remains possible. Mount to heaven, O superstitious prayer!

Can blue states protect their health insurance markets from Trump's executive order?

Can a state that wants to preserve ACA consumer protections protect itself from the executive order Trump signed today, which opens paths to segmenting the risk pools in the individual and small group markets? Consider the case of New Jersey, which had guaranteed issue (and, with no individual mandate, sky-high premiums) pre-ACA.

The Trump EO instructs Treasury, DOL and HHS to expand availability of short-term insurance, allowing it "to cover longer periods and be renewed by the consumer."  That's understood to mean allowing coverage for up to a year -- and so, via renewal, indefinitely, though subject to medical underwriting at renewal as well as at first purchase.  Short-term plans are not subject to ACA coverage rules.

At present, plan duration is limited to three months. Since  that rule only went into effect this April, extending the term to up to a year is not a radical shift from the ACA status quo.  But combined with weak enforcement of the individual mandate, and more exemptions from the mandate stemming from rising premiums, temporary plans available continuously are likely to weaken the ACA risk pool.

Temporary plans are subject to state regulation, however, and health law scholar Nicholas Bagley expects that to continue:

13/ The states should still retain authority to regulate short-term plans -- and to require them to adhere to ACA rules.

— Nicholas Bagley (@nicholas_bagley) October 12, 2017

How to hand the keys to an unfit successor

How do you hand the keys to the Oval Office to a man you've declared in no uncertain terms to be unfit for the presidency?

Obama's handwritten note to Trump, placed before Inauguration Day in the top drawer of the president's desk, is a carefully calibrated document -- a muted "don't be evil" plea on behalf of the nation, with goals distilled to the most basic: justice, security, democracy. Stark in its simplicity, it's generous without warmth, avoiding the hypocrisy of any hint of confidence in the recipient.

It begins with a depersonalized wish:

The senescence of the United States

About five years ago my father-in-law, then in his mid-80s, of sound mind, gave my wife power of attorney and turned over management of his financial affairs, after 60 years of capably managing them himself.  "That's how it often works," his financial adviser told us. "They're very hands-on, and then suddenly they let go."

That came to mind as I read this Times editorial board review of Trump's "leadership":

In short order, Mr. Trump has pulled out of the Trans-Pacific Partnership, ceding leadership on trade in Asia to China; refused to reaffirm the mutual defense commitment that has been the bedrock of trans-Atlantic security for half a century, forcing America’s European allies to think about dealing with threats like Russia on their own; and abandoned a landmark agreement on climate change signed by 190-plus other nations, ceding leadership on the issue to Europe and China, and, in the bargain, forfeiting the rewards of participating in a worldwide clean energy economy that the agreement will bring.

I'm not thinking of Trump here, but of the United States. Maybe, collectively, we got tired, our faculties sapped by 40 years of galloping inequality and risk shift, as we fell behind much of the developed world in education, opportunity, health care and income growth and outpaced our peers (all afflicted to some degree) in letting the superrich capture a growing share of national wealth and, concomitantly, power. The portion of our population mired in job loss, income stagnation, family and community disintegration and right-wing gaslighting reached critical mass.

A Sparer means to universal health insurance

Last November Michael Sparer, chair of Columbia's Mailman School of Public Health, proposed that managed Medicaid programs be used as a fallback for regions of the country in which no insurer was participating in the ACA marketplace.  Today Sparer went one better and proposed, in a NYT op-ed, that managed Medicaid replace the ACA marketplace:

Some liberals have proposed using Medicare, the federal health care program for the elderly and disabled, as the basis for providing universal health insurance. But Medicaid is the better fit. It has a more generous benefits package, is less costly and is developing more innovative care-management strategies. Moreover, the integration of the Obamacare exchanges into Medicaid would be relatively seamless: Many health plans are already in both markets...

Moderates in both parties recognize that the chance of success for an insurance marketplace that serves only the self-employed, part-time workers and small businesses, as Obamacare does now, is small. So why not eliminate the insurance exchanges — enabling Mr. Trump to claim he “repealed” Obamacare — while allowing exchange beneficiaries to buy into Medicaid, using tax credits to pay the premiums. Recent surveys showing that Medicaid beneficiaries are generally satisfied with their coverage, more so than their exchange counterparts, makes the case even more persuasive.

Of course this excites me, since so far as I can tell the only person who has consistently suggested that managed Medicaid, or something close to it, is the best way to serve those currently dependent on the individual market is...me. I have argued that using a solo public option to push private insurers' costs down is pushing on a string; that marketplace enrollees have given ample testimony to Medicaid envy; that insurers are happier in markets in which government effectively sets rates (happier than in the individual market, at any rate); and that managed Medicaid is the only path to fulfilling Trump's healthcare promises (not that those promises are worth anything).

Hastening to be slaves and tyrants

Here is C.S. Lewis' charming Screwtape, senior devil, who spends his time teaching"junior devils" how to tempt humans to hell. Last line is a blueprint for Trump and his minions:

The use of Fashions in thought is to distract the attention of men from their real dangers. We direct the fashionable outcry of each generation against those vices of which it is least in danger and fix its approval on the virtue nearest to that vice which we are trying to make endemic. The game is to have them running about with fire extinguishers whenever there is a flood, and all crowding to that side of the boat which is already nearly gunwale under. Thus we make it fashionable to expose the dangers of enthusiasm at the very moment when they are all really becoming worldly and lukewarm; a century later, when we are really making them all Byronic and drunk with emotion, the fashionable outcry is directed against the dangers of the mere “understanding”. Cruel ages are put on their guard against Sentimentality, feckless and idle ones against Respectability, lecherous ones against Puritansm; and whenever all men are really hastening to be slaves or tyrants we make Liberalism the prime bogey.

Obama calls Trump unfit for the presidency. Republican react in outrage, right?

Yesterday, Obama called Trump "unfit to serve" as president. In fact, he made the case at length.

Using the formal backdrop of a joint news conference with Prime Minister Lee Hsien Loong of Singapore, Mr. Obama suggested that Mr. Trump would not abide by “norms and rules and common sense” and questioned whether he would “observe basic decency” should he reach the Oval Office.

The president said he would have been disappointed to lose in 2008 or 2012, but added that he had never doubted whether his Republican rivals in those races, John McCain and Mitt Romney, could function as president or had the knowledge to make government work.

“That’s not the situation here,” Mr. Obama said.

Alarm bells went off for those familiar with basic political dynamics (or schooled, like me, by political scientists contributing to mainstream journalism in recent years).  Presidents polarize. When the president comes out in favor of something, the out-party turns agin it, by reflex. That goes triple in the Obama era, when the right wing scream machine has demonized the president's every move, including his birth.

When a democracy offers "one choice": Obama's haunted celebration

One of the enduring themes in  Obama's rhetoric is to embrace the messiness of democracy: to remind listeners that 'the other side may sometimes have a point,' to urge the necessity of compromise, to affirm that people on opposite ends of the ideological spectrum share some core values.  

It was all the more striking, then, that in his convention speech last night he placed Donald Trump outside the pale of this consensus allegedly underpinning all our battles over policy. In his 2008 convention speech, Obama praised John McCain's service to country and personal decency effusively while lambasting his polices; in fact the whole convention was structured to kill McCain with kindness. With Romney he was more caustic, suggesting in his 2012 convention speech that to vote Republican was to choose oligarchy. But oligarchy is on the democratic spectrum. The U.S. has always been an oligarchy to greater or less extent.

In this his valedictory paean to democracy, in contrast,, Obama asserted that there was only one choice. He ultimately placed the Republican nominee in the company of the destroyers of democracy, the nation's worst enemies: fascists, communists, jihadists. And the context in which he made that shocking but wholly appropriate charge is fascinating.

He began by evoking the "real America" as portrayed by Trump's precursor, Sarah Palin: the small town Bible belt heartland -- where ironically he, in a very real sense, came from. He then carried that "heartland" through space and time, to Hawaii and working class black Chicago and to the present -- and then to the entire world from which the U.S. draws its immigrants.

Trump, backwards and in denial

Some time ago, I noted that headlines beginning "Trump Blames" were not a rare occurrence. Deja vu of the same sort just struck as I read the words "Trump Walks Back." Yup...

Trump walks back comments on guns | MSNBC

www.msnbc.com/thomas.../trump-walks-back-comments-on-guns-708928579568

3 hours ago - Trump walks back comments on guns. Larry Pratt from Gun Owners of America criticizes the laws that were in place in Florida and claims that ...

D'Oh!: Trump Walks Back Positions on N. Korea and U.K.'s Cameron ...

www.usnews.com/.../doh-trump-walks-back-positions-on-...

U.S. News & World Report

May 20, 2016 - But the presumptive GOP nominee gives a thumb's up to the Brexit, another sticky foreign-policy wicket.

Donald Trump Walks Back His Only Detailed Economic Proposal ...

thinkprogress.org/economy/2016/05/05/.../trump-tax-plan-reversal/

ThinkProgress

Donald Trump Walks Back His Only Detailed Economic Proposal. by Bryce Covert May 5, 2016 2:24 pm. CREDIT: AP Photo/Charles Rex Arbogast. Republican ...

No one can say the people are deceived

I don't know what I can add to all the well-informed denunciations and warnings about Trump's demagoguery published in response to his post-Orlando speech.  See, e.g., Francis Wilkinson and Steve Benen. But the manifest depravity of this speech, which raised demonization of Muslims to something approaching Nazi levels, does highlight something basic about the choice before us that's perhaps hiding in plain sight.

The speech rendered all the more obvious truths about Trump that have long been obvious: 1. He is promising to abrogate the Constitution in fundamental ways. 2. He will say anything that he senses will inflame his followers and throw the media into a frenzy. 3. His solipsism is so extreme that there is no boundary line in his mind between what works for him and what is true. 4. He's such an transparently self-aggrandizing fraud that anyone, regardless of education or political engagement, should be able to see through him in two minutes. "Anyone" includes grade school children.

The moment when the rise of the oceans began to slow

Not to minimize the dangers posed either by ISIS or Trumpism, but the odds are pretty good that both will fairly swiftly end up in the ashcan of history. Meanwhile, as we in the US obsess about both, a 195-nation climae accord has been negotiated in Paris that may lay the foundation for  continued human progress without catastrophic interruption.

While the US is maintaining a relatively low profile at the conclusion, the accord would not have been possible without forceful and effective climate action on the part of the Obama administration and the long, intensive efforts of John Kerry. Thank God we have a president who knows what's most important, knows how to prioritize and persist.

Obama was mocked for grandiosity when he laid out this hope on the night he secured the Democratic nomination in 2008 (my emphasis):