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Federal Medicaid cuts in the OBBA are hitting NC in two months and they're pretty severe. The effects of this funding cut will slash a lot of things that I think most people right or left wing would agree are useful to have.
First every provider gets at least a 3% rate cut. Then due to the share of spending, a much larger rate reduction of 10% is on inpatient and residential medical institutions. This includes acute care hospitals, nursing homes, PTRFs (basically the mental hospitals/modern asylums), and intermediate care facilities (these are for intellectual/developmentally disabled people who need intermittent nursing).
The rate reductions will see an already stretched mental health system in the state need to cut back on access more. For an admin that claims to want more institutional treatment of the mentally ill, addicts, etc, this will ironically be one of the biggest deinstitutionalization effects in the state.
Another effect is the removal of GLP-1 drug coverage for obesity. I don't think I need to prove that they're very effective at weight loss, and obesity is a major health issue so a lot of people finally finding themselves losing weight are going to be hurting in the next few months as their prescriptions get cut. While GLP-1 medications isn't yet a net positive financially, the impact it has on people's health can not be ignored.
This also will likely hurt their ability to ensure proper compliance with the program.
And as they point out
Medicaid reimbursement rates are already lower than commercial insurances tend to be and plenty of providers won't take it for that reason already.. This will likely get even worse, as poor and disabled people struggle to find providers.
This is especially going to hurt the poor rural areas (ones that voted Trump in) that are already struggling financially and don't benefit as much from economy of scale like the local areas.
About a week ago The Asheville Citizen Times did a report on the nearby rural Mitchell county and their upcoming fears over the cuts.
For example, they're worried that the already tight financials of the Blue Ridge Regional might be forced to close
Blue Ridge Regional is the hospital of Spruce Pine, a town you might recognize from coverage of last year's storm as being one of the only places in the world with high quality quartz. It's still important to have some people in the surrounding region for this work (and other work providing for the quartz industry and workers) but their small size as mentioned before doesn't benefit from economy of scale and impact of automation has had a toll on their wealth too. Still they're very important to have around, making up anywhere from 80-90% of the high quality quartz used in the world. And sometime soon, they may be without a hospital, a hospital that was pretty useful during Helene.
So that's the issues my state is going to be facing soon. How is it going to impact your state Motte users?
When reading a news article, let the word "could" serve as a little bell. In journo-speak, it means "isn't technically impossible". When someone knows they'll be sued and they'll lose if they say something "will" happen, they say it "could" instead. Any time you see the word "could", it negates everything that follows.
I've a similar feeling when the word 'must' appears in journalism.
In other fields, 'must' is an obligation, or a consequence of a previously established condition. An apple must fall when subject to the law of gravity. A spouse must maintain a certain level of relations lest they be divorced into an ex-spouse. A racer must move faster than the competition to win. A legal contract must be fulfilled to avoid the penalties of breaking the contract.
In journo-speak, 'must' is much more likely to mean 'something the writer wants the subject to do, but they don't actually have to do.' The politician must take a certain position. The government must take a certain policy. In such cases, though, the consequences of not abiding the 'must' are, well, that they clearly did not have to do what they must have done.
To me it's a red flag of advocacy journalism, outside of specifically technical/consequential framings of the earlier sense.
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That heuristic goes way too far into the point of absurdity. Sometimes they say could just because they don't want to appear like psychics with 100% accuracy when they aren't that. Especially since policy can always change. You don't wanna say something will happen only for the underlying causes to disappear underneath your claim.
Hedging oneself with careful verbiage about one's predictions about the future (which I hear are quite hard to get right) is indeed good practice. However, this argument doesn't make that case. Because there's nothing wrong or shameful or embarrassing or negative at all about saying that something will happen if [underlying cause] holds true. This is a positive claim about cause and effect which could be proven false if the underlying cause continues to hold but that thing doesn't happen. Unlike saying something could happen, which is really just a nothing statement that is almost entirely unfalsifiable.
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You could be right.
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Here is a fun idea maybe the junk food producers lobbied to get the coverage removed. It is a net positive in cost for everyone except those who profit to keep people eating pseudo-food and selling medications to fix the symptoms caused by obesity.
I just googled "medicare GLP-1 costs", and found this article:
I am happy to hate Trump because he cuts of GLP-1 for millions. I could probably be persuaded to hate Trump because he wastes billions of dollars on GLP-1 drugs.
Unfortunately, I can not help but notice that both reasons to hate him seem mutually exclusive. While it is nice to know I can hate him no matter what he ends up doing, until he moves out of that superposition of bad options, I am stuck in a state of cognitive dissonance.
The annual US revenue of Novo Nordisk (Semaglutide) seems to be 45G$, while that of McDonalds is 25G$. Likely, NN's profit margin is a bit higher, so they could afford to out-lobby fast food.
--
The question if GLP-1 drugs are a net positive financially for the medical system is extremely cynical. Given that the lifetime patient costs mostly occur in their last years, it basically reduces to of the obese cost more before croaking than the non-obese or not. From a purely financial consideration, the most effective intervention (short of killing them outright) would probably be to offer free base-jumping courses and equipment to medicare patients. The government might spend 10k$ per death caused, which would be a lot cheaper than bypass surgeries, chemotherapy or keeping a dementia patient alive for a decade.
The compassionate, EA-ish metric would be cost per quality adjusted life-year (QALY). Both measles vaccines and doing a full-body MRI scan for tumors once a month are interventions which would boost the QALY of the median patient. But the former is pretty cheap and pretty effective and the latter is very expensive and not very effective, so we pay for one and not for the other.
For GLP-1 agonists, a lot depends on the cost per month.
That fortune article with their moral panic about fraud mentions:
What they forget to mention is that this is peanuts. If half of the patients enrolled with medicare get GLP-1 drugs, that is 35M patients. So the cost per patient per year would be 200$. That is a factor of 60 less than the sticker price of 1000$ a month! If somehow every obese American defrauded the US government into paying 200$ per year for GLP-1 drugs, that would be even better.
I do not think that this is happening, though. I recently turned to biopiracy to knock a few points of my BMI (I will write an article about my experiences on LW at some point), and I will likely spend north of 100$/year on peptides from China. Of course, the medical system will not have patients reconstitute peptides in their kitchen and inject what they think is the correct dose using insulin syringes with no medical or pharmaceutical oversight. Even weekly subcutaneous injections of saline would probably cost 500$ a year.
Isn't it a Danish company? I've wondered about that because I've seen lots of concern about cuts to research funding citing GLP medications as an example, but it seems odd that my tax dollars payed for the research, and now I would have to pay the Danes, as it were, to use it.
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I don't see the contradiction. Basic research is mostly funded through taxes of Western countries, and here the US was most prolific. This research is then made available to the public (though sometimes you have to pay Elsevier, which sucks).
Pharmaceutical companies then use that basic research to discover active ingredients and go through the long, grueling and expensive process of getting them approved as pharmaceuticals. In return, they get temporary monopolies ("patents") on their active ingredients. There is a lot to criticize about how this system works. Details about what can or can not be patented, and how the latter means that nobody will pay to turn it into approved pharmaceuticals. Drug pricing both generally and within the US in particular. That the financial incentives make it much more profitable to sell lifestyle medication to rich Westeners than to cure debilitating diseases in the developing world. The general role of the medical priesthood as gatekeepers which determine which substances I can or can not put into my body.
Criticizing that in this case, one of the companies which holds the patents is nominally Danish (Eli Lilly is nominally US -- but at the end of the day, most are publicly traded and probably have campuses in multiple countries) seems rather low on that list.
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Paging Alfred the great... a fine king, the best! He had some great people in Wessex, it was a very dangerous situation. Thank you for your attention to this matter!
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Yeah, this whole thread, I'm thinking, "someone mention that the costs are too high", and you got the closest. If you showed this thread to Trump, he'd probably argue that he's working on pressuring the drug companies to bring prices down. How likely that is to work is another matter entirely.
I suspect that, if prices don't come down, this will mean budget cuts for my workplace, and that will almost certainly result in some unpleasantness with supplies and their quality.
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While they're not currently a net positive financially, there's a lot of invisible societal gains even for thin people.
Less fat people in general means a better looking world. You'll see less chubby kids with chubby parents while at the mall or the park or other public spaces and more attractive looking people. You'll have more hot women and men available for dating, no longer having to settle as much on looks for someone with a good personality match.
Less fat people gives gains elsewhere like not ending up sitting next to a fat guy on a plane or being able to do physical activities with your formally fat friend. All sorts of little small annoyances and issues that will be alleviated by a thinner world.
Resources can benefit even more from economy of scale when we can start assuming people are within a certain size range more often. For example clothing stores can offer larger selections in your size and not have to spend as much space on having XLs and XXLs and the like because the market demand for those will be much smaller.
Your family and friends who are fat will be healthier and prettier and that's just a good thing too if you care about your family and friends.
And that's just on top of not currently a net positive financially. We might be able to improve on it more and get to the point where we have a world of thin hot people for cheap.
I would argue that all of these benefits (which I do not dispute) can be captured very well by the QALY/$ picture -- just add a term for quality of life effects on people other than the patient.
From a purely medical system costs picture, they are all externalities.
Still, from any non-terrible POV, GLP-1 drugs will at the latest be worth it at least when the patents run out and they can be sold for what it costs to produce them.
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Well I agree that it is cynical. But I also find the view that it is a pure plutocratic exercise of who has the most lobbying dollars as equally cynical. Those who are interested profiting the issue that Semaglutide solves is not only McDonalds. It is is a whole host of US domestic companies that extract profits by providing both the cause and management of the symptoms as a result. A weekly shot from a Danish company is a threat to the bottom line of fast food, healthcare providers recurring visits and lifelong medication by domestic pharma. Maybe the politicians gives patriotic rebate to the lobbyists?
But Nestle and coca-cola are already losing a fight with the Trump admin; obviously someone can outcompete them if need be.
Yeah but my hypothesis has nothing to do with Trump. It is just suggestion to ask: "Cui Bono?". I make claims with little elaboration and very little proof but gives my view that it is an useful avenue of thought if it is simply matter of corruption regardless who occupies the White House.
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As usual per republican policy, it'll probably affect poor areas more than rich areas, and rural areas more than urban or suburban areas. Can any poor or rural republican reply if they think otherwise? I can understand why most republican policy is in the best interest of republicans, but I'm honestly stumped on this. Is it legitimately just ideological consistency? A willingness to suffer to Do The Right Thing?
Rural republicans are mostly people who are stuck 'in the gap' where they don't have medicaid to begin with- they make too much. Rural medicaid users might vote republican if they voted, but alas, they do not.
You are forgetting that medicaid is not actually universal healthcare. It's entirely possible to go without healthcare in the US because you don't qualify for welfare. There are some pretty brutal benefits cliffs.
Are you a poor or rural republican? Your logic makes sense, but I'm looking for insights specifically into their psychology.
I am connected to two tribes of rural republicans, albeit not the poorer sorts. Having been around poor people who didn't like democrats, their likelihood of voting is rather low.
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Very true, and in some states it's a cliff on both sides of the coin. In some states that didn't adopt the medicaid expansion portion of obamacare you can't get government insurance in a situation where you don't have a job yet if you had anything other than the very lowest paying job possible you wouldnt qualify anyway.
I understand the reasoning behind not wanting to subsidize jobless bum's insurance, but it isnt hard to imagine a case of a non bum falling into this crack and having to go into medical debt over a broken arm or whatever.
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Insufficient resolution in your maps. The rural Republican counties that are pointed to as examples of Republicans voting against their economic self interest don't consist of 100% Medicaid users, they consist of a class of Medicaid users and a class of non-Medicaid users.
The latter class votes Republican because they hate the former class and want them thrown off Medicaid. This isn't poor people voting to throw themselves off Medicaid, it's contractors voting to throw addicts off of welfare.
Empathy and charity are easier at a distance. Racial Diversity is correlated with racist attitudes in the general public; this is equally true of economic diversity.
This is also Republicans possibly losing their rural hospital
From the article again
This is an all-republican board concerned about the impact.
Unless the good hard working rural Republicans are superhumans who don't need a hospital and anyone who is concerned is just a RINO, it's going to hurt them too because the economics of rural healthcare is already tight.
Actually, many rural republicans I know do self identify as people who don't need to or just don't go to a doctor. But that's more a matter of stupidity in those cases.
At no point am I arguing that rural healthcare won't be harmed, I'm arguing that they don't think it will be.
Yeah, a lot of these people think doctors are for 1) childrens and maternal care 2) emergency medicine and 3) really serious illnesses like cancer. Normal adults go to chiropractors, nutritionists, etc.
What are all you guys going to nutritionists and chiropractors and so forth for? Doesnt all that stuff just happen automatically if you eat right and exercise?
I can see a reason to go get cancer, heart, etc, screenings starting at a certain age, but I actually am quite confused why a healthy lifestyle 20-50 year old needs doctors at all beyond screenings and acute things.
How old are you? I would say things generally start going wrong at about 30 - I got a gastric problem from a not-great diet that had been fine up until then plus some heart stuff, my friend did something permanent to his ankle skiing, somebody else started getting serious insomnia, etc.
Early 40s. The skiing injury/insomnia/gastric/heart items are all things that I would put in an acute, or at least "actual malady", category. Your friend's lingering ankle injury is probably more like a chronic condition than acute if we are being really choosy on our diction, but it is nonetheless something being clearly wrong, not the maintenance/preventative work that a nutritionist would generally be for someone without a physiological nutrition/diet problem. I am still missing the purpose of chiropractors, nutritionists, etc, for "normal adults".
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Because few Americans lead healthy lifestyles.
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https://youtube.com/watch?v=ERNAqqNSId0?feature=shared
This matches my experience (growing up in a rural deep red area) of medicine. You go to the doctor for broken bones, bleeding you can't stop, or when you're in enough pain your wife makes you go.
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At least here in the Appalachians, those rural hospitals have been closing down since at least 2010 and nobody other than the local residents has given a shit.
Could you explain how this is different and why I should be more concerned? Or, for that matter, why people who aren't from here and didn't care then should care now?
That's not true at all, there's programs like the rural health fund and the the start of rural emergency hospitals program in 2023 and stuff like that being created to help keep them open and functioning.
Rural healthcare struggles to break even yet alone turn a profit, even more would be shutting down if it wasn't for Medicaid/Medicare and programs like that.
And there's extra benefits even within these programs like how sole community hospitals get higher rates
It's arguably not enough, but it's definitely helping rural healthcare stay afloat when they're literally just given more money.
It's not different, we are doing stuff to try to help our rural hospitals already and we should keep doing that stuff and help more.
Rural communities and urban communities depend on each other. Urban zones might be the main money areas but they need things from the rural areas still like food or that high quality quartz.
Also ya know, empathy, religious duty, etc other general reasons to help out others in need.
Also keep in mind these cuts aren't impacting just the rural areas anyway. Less funds for mental institutions and the like will have an impact on the urban areas.
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But does the former class not also vote Republican? Folklore seems to say that they do, and are motivated by a mixture of "willingness to suffer to Do The Right Thing" and spite ("we suffer either way, but at least this way we get to wipe the smug grins off the city-dwellers' faces").
A lot of rural welfare users simply don't vote. It's extremely common.
The rural poor also understand that they're a peasant class and hate everyone who's in line ahead of them, which to be clear is most people. Given the economics of rural areas these people are a lot more dependent on local elites(who are very solidly republican) than the poor elsewhere; and a condition of that dependency is voting correctly.
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I genuinely believe what you call city-dwellers have absolutely no idea how strong that impulse is in a lot of rural Americans.
If I asked ten of my neighbors if they'd do something that harmed themselves if it hurt the nearest city twice as bad, I think twelve of them would say yes.
Trump's election in 2016 and 2024 represent the apex of this phenomenon, but it's not the only one.
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This is admittedly speculative due to a lack of contact with the former class but my general assumptions are that they aren't exactly hardcore voters to begin with.
I also suspect that if they do vote for the GOP, they probably aren't thinking "I'm going to get thrown off of Medicaid but it will make the blue-haired freaks unhappy so it's a net win for me," they are voting GOP under the theory that entitlement reform never happens but maybe their neighbor with the string of misdemeanor assaults and restraining orders will finally be locked up for good, or that it will help the economy, or things like that. My general assumption is that people who are "on the fringes of society" in the sense of being on welfare and not being particularly poor are more likely to be sensitive to the economy and crime, not less.
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There's two separate questions in there.
Are they in the Taker class?
Do they perceive and identify themselves as being in the Taker class?
Broke trailer trash generally abhor trailer trash, which they perceive as their neighbors rather than themselves. "I'm poor because I have to support all these people on welfare," "I'm a hard-working man, if I could, and my disability payments would be higher if it weren't for all the immigrants we're supporting..." "I'm just a drinker, he does meth," "I only do a little meth I'm not an addict like that guy over there," "I wouldn't be on the meth if it weren't for trying to compete with illegal immigrants..." There's various degrees of magical thinking involved in excusing one's own temporary circumstances, such as "Rural areas really produce things while urban gdp is fake and gay" or "Once you throw the bums off welfare and the immigrants out, I'll make more money and I won't need Medicaid." I do not think many GOP voters perceive themselves as takers, even if they mathematically are.
I do not think a significant number of Republican voters believe that bad things (for them) will result from Trump's policies and are willing to suffer for them. You can tell because Trump doesn't talk that way, more or less ever. They think that the policies Trump is pursuing will result in the instant improvement of their lives.
This might have been true at the beginning of the year, and still be true for a majority of people who will be badly affected by his policies. I am not sure that it will still be true at the end of his administration, depending on how bad his policies will get. He got a trade deal with the EU which will increase revenue and not directly hurt US industry (but I am less optimistic about the long term effects for the US hegemony). However, a trade war with China still has the potential to wreck the economy. Likewise, cutting medicare has the potential to be ruinous for a lot of his voters.
Most people have some awareness of their relative economic situation under different administrations. They suck at attributing it to specific policies (and often make off-by-one errors when policies take long to yield results) and economic effects unrelated to government policies, but they will notice if they are better or worse off. A few idiots will double down on their partisan preferences when things go badly for them, but I am hopeful that many will not vote for the leopard eating people's face party after having their face eaten for 3.5 years.
You're assuming the horror stories about the effects of Trump's policies are going to be both true and one-sided. This may not be the case. If his policies hurt Republican "takers" but help the working class (according to their own perceptions), that's probably a net win for Republicans. Republican takers are probably one of the least-reliable voting blocs (especially since Republicans lack the ground game to get them to the polls), and the working class has only recently turned Republican.
Yeah — the other poster who is anti Trump believes Trump’s policies will be bad and therefore Trump’s voters will abandon him.
That is not unreasonable for anti Trump person to believe but isn’t necessarily the best reflection of reality. Take tariffs. Suddenly Democrats hate tax increases*. But it’s far from obvious how much of a tax increase it will be for American consumers. First, tariffs are on the import price which often is a small fraction of the overall price. Second, some of the incidences of the tax will fall on non Americans or capital. To the extent the tariff revenue is used to shrink the budget deficit, it could on net help consumers. Doesn’t mean tariffs are good (or this will work) but the idea that it’s the end of the world doesn’t make sense (especially by people who were pushing for mark to market taxation and significantly higher corporate and individual tax rates).
Take immigration as a concrete example. Jobs are meh but the mix of the jobs were foreign less and natives more. A dem would point to “limited job growth” whereas a Republican would point to “our people are getting jobs.”
I would bet all things equal life is pretty similar for a lot people on 2028 as it was in 2024. I think the one thing Trump could do to change that is passing some kind of massive zoning reform (he is stealthy doing some of that for large projects via the EPA).
*there are of course arguments that tariffs are bad kinds of taxes precisely because they are easy to avoid and therefore people will make non economic decisions. But this second order thinking is always absent in democrat plans so hard to take it seriously.
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I'd say it's that, despite all the talk of MAGA having wholly taken over the Republican party, much of the institutional core of the party is still the "what's good for Wall Street is good for Main Street" crowd. As someone in a several-hour-long Youtube video (on the county-level political map for Congressional elections, every two years, from the end of WWII to the turn of the century, with a focus on how, once you set aside the highly-granular and variable presidential elections — particularly the Reagan landslide — the South didn't really stop voting (D) until the 90s, as all the old "Dixiecrats" finally died, and the new generation of Dems were abandoning the working class for the professional managerial class and minorities) I once watched said, "the Republican Party was founded as the party of New England banking interests… and that's what it always will be."
I also recall, but can't find again, an interview with a GOP campaign strategist who got a bit too candid with the interviewer and ended up saying something to the effect that Republican candidates already know that their job is to make empty promises to working class rubes to get elected, then deliver for the "donor class" instead once in office, so his job, as strategist, is to help the politicians lie to those flyover rubes more effectively.
Both party elites are elites — while only Hilary may have said it openly, plenty of the top people in both parties consider blue-collar rural whites "deplorables" — R's are just the ones more reliant on winning their votes, and thus given more incentive to hold their noses and pander.
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Watching Trump's approval rating fall even more will affect my mental state by making me smile and laugh as Americans realize they fell for it again
Please remember that this is not PoliticalCompassMemes; pointing and laughing in the style of Nelson Muntz invites only heat, not light.
That's incredibly fair
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The first article is about how all of this was locked in back in March by the Democrat governor. There's one off-hand reference to the OBBBA, and no effort made to connect anything.
Which makes sense, since, last I saw, the bill just decreased the rate of increase in spending. Remarkable how consistently people miss that. Some antimemetics shit, really.
Despite having a Democrat governor, the Republican (almost) supermajority in state congress and the past decade of slowly removing powers from the governorship combined with NC already having a low power governorship means a lot of things that would normally be in the governor's hands are instead in the state Congress. North Carolina might even be the weakest governor in the nation
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Just curious where you are reading that? The NC Newsline article doesn't say that:
The NC Governor doesn't have much power because the NC legislature has a veto-proof Republican majority so I don't really see how you could lay this at his feet.
Edit: Oh, actually they aren't technically veto-proof anymore by the margin of one seat. One or two Democrat representatives have also been voting in step with the Republicans to override governor's vetos.
That's a valid enough point. I checked for the governor, but didn't think to look at the legislature.
Regardless, there's no reason to think there's a connection to Trump and the OBBBA based on that article. This was decided at the state levels months before the bill passed, or was even finalized.
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