Wednesday, July 26, 2017

Goodbye, Affordable Care Act

GOP’s Senate Victory the First Step Towards Getting Rid of Medicaid, Medicare and Social Security


Copyright © 2017 by Mark Gabrish Conlan for Zenger’s Newsmagazine • All rights reserved

On Tuesday, July 25, 2017 — a date which will live in infamy — the United States Senate voted to repeal the Affordable Care Act (ACA, so-called “Obamacare”) and repudiate once and for all the idea that the federal government either will or should guarantee all American citizens access to health care. Officially the vote was simply a so-called “Motion to Proceed” — the Senators giving themselves permission to consider various alternatives for getting rid of the ACA — but don’t let that fool you. It’s only a matter of time before the Senate passes a bill either to “repeal and replace” the ACA or to repeal it outright with no replacement, and the only real suspense will be just what, if anything, will replace the ACA when the Senate finally acts and the House of Representatives, which already passed their own “repeal and replace” bill last May, either adopts the Senate version or sets up the standard “conference” process by which the two houses of Congress reconcile differences in the bills they pass.
The only open question is just what the Republican caucus of the Senate can come up with which will satisfy both the so-called “moderates” and the hard-line Right-wingers who are driving this process and will be satisfied with nothing less than a full-blown ACA repeal that gets the federal government out of the health care business once and for all. That’s why the Senate leader, Mitch McConnell (R-Kentucky) plans to have one vote after another on various schemes to repeal the ACA, some of them attached to a “replacement” and some attached to nothing at all, until he finally comes up with something that can get the votes of the necessary 50 Republican Senators. With the math so tight — there are 52 Republican Senators, 46 Democratic Senators and two independent Senators who caucus with the Democrats — McConnell can afford to lose only two votes in his caucus to keep the vote total at the 50-50 tie which will allow Vice-President Mike Pence to use his Constitutional power to break the tie and pass whatever it is McConnell wants.
Like the brain-eating ghouls in George Romero’s Night of the Living Dead and his other follow-up films (and Romero’s death in the middle of the Senate’s ACA deliberations seemed macabrely appropriate), the bills to “repeal and replace” — or just “repeal and not replace” — the ACA keep coming long after they’ve been pronounced dead. The House of Representatives got so stuck on their version, which they called the “American Health Care Act” (AHCA, which seems to require a verb in front of it, like “Destroy American Health Care Act” or “Eviscerate American Health Care Act,” to describe its contents accurately), House Speaker Paul Ryan pulled it from a vote in March. But it was back, even meaner and nastier than before, in May, when Ryan scheduled another vote and even Republican House members who had criticized the bill before as too harsh voted for the new, worse version anyway, and it passed.
The Senate’s own version, the Better Care Reconciliation Act (BCRA) — “reconciliation” not as in “working to bring people together and settle their differences,” but as in “budget reconciliation,” an arcane process that allows the Senate to pass something with a simple majority and not risk having it filibustered by the minority — first surfaced in June after a secret two-week process in which McConnell and 12 other hand-picked Senators — all Republican, all male, and all white except Ted Cruz (R-Texas) — drafted the bill in such lordly isolation from the rest of the Senate, let alone the rest of the country, that not even all the members of the “Gang of 13” knew for sure what was in it. When they finally released the BCRA draft June 22, just about everyone outside the Republican Senate caucus was horrified. Like the House bill, it replaced the direct subsidies that had helped people purchase individual health insurance policies under the ACA with tax credits that wouldn’t benefit the lowest-income people.
Like the House bill, it eliminated the federal guarantee for Medicaid, the 1965 health-care program for the poor. Instead of paying a share of whatever the states needed to cover everyone they decided should be eligible for Medicaid, the federal government would put a cap on its contribution and raise that only by the general rate of inflation — not the rate of increase in health-care costs, which is several times that. The Medicaid cuts, which both the House bill and the original draft of the BCRA used to fund enormous tax cuts for the richest Americans, are crucial to the bill not only because the ACA relied largely on expanding Medicaid coverage to increase Americans’ access to health insurance, but because Republicans have never liked the idea that the government should have any role in guaranteeing people’s access to health care. On the July 25 Hardball program on MS-NBC, host Chris Matthews point-blank asked former Republican Party chair Michael Steele if he thought the government should guarantee every American access to health coverage. Steele answered, quickly and bluntly, “No.”
There were other nasty wrinkles in the BCRA, including a total ban on government funding of Planned Parenthood and a policy that no health policy that covered abortion should get so much as one dime in assistance from the federal government. An amendment suggested by Ted Cruz, which the most hard-line Right-wing Republican Senators insisted on including in the bill before they would support it, would allow insurance companies to sell low-cost, high-deductible, highly restricted health insurance policies if they also offered ones that met the quality standards of the ACA. One of the principal arguments made by supporters of this amendment was that, since men don’t get pregnant, they shouldn’t have to pay for policies that offer maternity coverage — ignoring the obvious biological fact that every time a woman gets pregnant, a man has been involved in the process. That’s what you get when you draft your bill behind closed doors and include only men. It’s probably no accident that the two Republican Senators who had the courage to vote down the Motion to Proceed on July 25 were women: Susan Collins (R-Maine) and Lisa Murkowski (R-Alaska).
When the BCRA draft finally saw the light of day, just about everyone was horrified. The Congressional Budget Office (CBO), a nonpartisan body that’s supposed to give Congressmembers and Senators objective advice about the outcomes of a potential policy, said that 22 million Americans who now have health coverage would lose it under the BCRA. (Their estimates for the House bill were 23 million and for a simple repeal of the ACA with no replacement were 32 million.) Health insurance companies, who were already jacking up premiums for individual policies under the ACA — one of the big pieces of evidence Republicans have used to argue the ACA is self-destructing and needs to be repealed and replaced — said that the Republican alternatives would be even worse: they’d get rid of the widely hated “individual mandate” that requires all Americans to buy health insurance and therefore screw up the “risk pool.” What they’re afraid of is that, without a mandate, people won’t buy insurance until they get sick and actually need it — and with fewer healthy people paying into the pool, they’ll be spending more money to cover more sick people and will have to raise everybody’s rates to make up for it.
When Congress left Washington, D.C. for the July 4 recess, those few Congressmembers and Senators who dared to go home and face their constituents in town meetings got an earful. Senators and Congressmembers who didn’t hold town halls found people, many of them in wheelchairs or otherwise visibly disabled, picketing and in some cases occupying their offices, saying if one of the Republican health bills passed the loss of Medicaid coverage would literally kill them. Republican governors who had chosen to take the ACA’s opportunity to expand their Medicaid rolls to covered their states’ uninsured, like John Kasich of Ohio and Brian Sandoval of Nevada, protested that the Republican health bills would break their states’ budgets because they’d either have to make up for the federal Medicaid funds they’d lose or, more likely, cut back the number of people eligible for Medicaid and/or the services offered them.
Nonetheless, Mitch McConnell is keeping the Republican drive to repeal the ACA alive in the Senate — and after the July 25 vote on the Motion to Proceed, it’s a virtual certainty that he will be able to get some sort of ACA repeal through the Senate and President Donald Trump, who’s said he’s just waiting at his desk at the Oval Office with a pen, will sign it into law. On that dark day, not only will the United States government immediately cut millions of people off of access to health care, some of whom will quite literally die without it, it will turn its back on the hope of many who supported the ACA as the first step towards bringing the United States in line with every other economically and industrially advanced nation in regarding health care as a right, to which all residents are entitled and all pay for collectively through taxes.
The Republican attitude towards health care is exactly the opposite. They regard health care like any other commodity, to which The Market should control access. If you can afford health care, the Republicans believe, you should have it. If you can’t, you should do without or beg for your care from family members, friends or churches. House Speaker Paul Ryan signaled his real intentions when the House passed the AHCA and he said, “This is not an end, it’s only the beginning.” What it’s a beginning for is the ultimate Republican goal to repeal all America’s social insurance programs: the Affordable Care Act, Medicaid, Medicare and the big one, Social Security. To the ideologues currently in charge of the Republican party, it’s none of the government’s damned business to help people have access to health care or to keep from being poor (or impoverishing their families) in their old age.
Quite a lot of the commentary on the Republican health bills has essentially run along the lines of, “How can they do this?” How can they blithely vote for a bill that takes health coverage away from 22 or 23 or 32 million people? How can they literally step over people in wheelchairs on their way to their offices and vote for a bill that could kill their visitors? How can they negotiate people’s access to health care away in secret and vote on it in such unseemly haste? Why, this line of argument runs, are the Republicans so cruel? The answer, as I’ve explained in previous posts on this blog, is, in one word, Libertarianism.

Libertarianism and Leninism

Libertarianism, in short, is a political philosophy that holds that the individual is supreme and no person owes anything to anyone else. As its founder, novelist, essayist and lecturer Ayn Rand, summed it up, “I will not live my life for any other person, nor ask another person to live his life for mine.” What this translates to in politics is the belief that the government has no business taxing the rich to pay for services for the not-so-rich. To do that, Libertarians argue, is theft and enslavement. When Rand was asked the question a lot of people are asking about her ideological heirs in the Republican Party today — what do you do about the sick and disabled; if you’re not willing to have government help them, do you just let them die? — she replied, “Misfortune does not justify slave labor.” In other words, a government has no right to take tax money from the rich to keep not-rich people from dying: that just enslaves the rich to the not-rich.
Indeed, one of the key elements of Libertarianism — like its 19th-century predecessor, Social Darwinism — is the belief that rich people are actually intellectually and morally superior to non-rich people and represent a higher order of humanity, a step forward in human evolution. Libertarians generally divide society into the “makers,” the handful of intellectually brilliant, morally unassailable rich people at the top who are responsible for all human advancement and progress; and the “moochers” or “takers” who want what the rich have without being able or willing to work for it and get it themselves. Rand expressed much of her philosophy in novels like The Fountainhead (1943) and Atlas Shrugged (1957), and one of her plot devices was to have her super-rich heroes lose their money due to the machinations of all those pesky moochers and takers — and then, through their intellectual brilliance and physical and moral prowess, get it all back again.
Much of what separates the American Right from the European Right stems from its wholesale embrace of the Libertarian ideology. When Donald Trump ran for President he deliberately confused a lot of people by sounding more like a European than an American Rightist. Europeans like Britain’s Nigel Farage, France’s Marine le Pen, the Netherlands’ Geert Wilders and Austria’s Jorg Haider didn’t question those countries’ social insurance systems and safety nets for the poor; rather, they justified their opposition to immigration largely on the basis that social services should be reserved for the “real” British, French, Dutch or Austrians, not for swarthy, dark-skinned people from other countries with different cultures, languages and religions.
When Trump ran for President he posed as a European-style conservative pledging to protect Social Security, Medicare and Medicaid. He viciously baited immigrants but framed his arguments against them partly in cultural terms — they’re criminals, rapists, terrorists who want to take what we have and bring our system down instead of assimilating — but also on the ground that America was being “overrun” with immigrants who would overwhelm the social safety nets and thereby reduce the amount of aid available for “real” (i.e., white) Americans. But he’s actually governed as a hard-core Libertarian, and I suspect that’s because Libertarianism feeds the two things most important to Donald Trump: his fortune and his ego. Not only does Libertarianism generate social policies that will make Trump even richer than he is, it flatters him by telling him that he’s a better, more evolved human being because he is super-rich.
There’s another model for what the Republicans are doing these days, and it’s an odd one. It’s an authoritarian Russian leader whose first name is Vladimir and whose last name is five letters ending in “n.” No, not Vladimir Putin: Vladimir Lenin, the founder of Russian Communism who took over his country in 1917 and started a tyrannical regime it took 74 years to get rid of. It may seem inconceivable that modern-day U.S. Republicans would have any reason to like Lenin when they hate, loathe, despise and detest everything he stood for ideologically — but they admire him immensely as a strategist and a tactician. Lenin literally wrote the book on how a minority of a society can, through sheer determination, will and the ability to take advantage of crisis situations, maintain power indefinitely, stifle all dissent, and push through an unpopular program.
The book was called What Is To Be Done? Lenin published it in 1902, and it was a strategy for the takeover of Russia that relied on some basic rewrites of the theories of Karl Marx. Marx had believed that capitalism would inevitably collapse and be overthrown in a revolution led by the “proletariat” — the industrial working classes. One obvious question was how would the proletarians who made the revolution learn how to run the society and the economy once they won. Marx said it would essentially be through on-the-job training: the skills the proletarians would need to acquire to organize and win their revolution would enable them to run things once they won. Lenin disagreed: he said that on their own the workers would only get as far as organizing trade unions.
To go beyond that and actually contest for power, Lenin said, the workers would need a small core of intellectually educated and fanatically dedicated experts in Marxist theory to run the movement on the workers’ behalf. He called this group a “vanguard party” and said they should operate according to a principle he called “democratic centralism.” What that meant in practice is that the members of the vanguard party should settle their differences behind closed doors: once they made a decision and announced it publicly, every member of the vanguard party should fully stand by the decision as it was communicated to the proletarians who were their supposed constituency, as well as any remaining capitalists who were still resisting the revolution and anyone else who could conceivably oppose them. In other words, to the outside world the vanguard party must appear to be unanimous, even when they weren’t.
The obvious flaw in Lenin’s strategy was that there was no outside check on his “vanguard party,” no institutional arena through which people with different ideas of how to do things could challenge its authority. The “vanguard party” that seized power to set up a “dictatorship of the proletariat” could all too easily become a dictatorship over the proletariat. This flaw was noticed as early as 1904, 13 years before Lenin and his party actually seized power, by German socialist Rosa Luxemburg. She read What Is To Be Done? and wrote a scathing essay in reply, “Leninism or Marxism?,” in which she correctly predicted that any revolution that won power by Lenin’s tactics would degenerate into tyranny.
Lenin’s political writings and his success in implementing them and winning absolute power for himself and his party in Russia became a role model for many other would-be dictators — and not just fellow Leftists, either. By chance I recently read Leonard Schapiro’s history The Russian Revolutions of 1917 — the first one, in February/March, which overthrew the Czar and attempted to establish a democratic republic in his place; and the second, in October/November, in which Lenin and his party seized power, overthrew democracy and started a monopoly on political authority that lasted three-quarters of a century — and got a cold chill when he explained that the the secret police force Lenin founded, like many of his other authoritarian policies, “came into existence as response to the conditions that arise when a minority is determined to rule alone.”

The Republicans: A Minority Determined to Rule Alone

There can be little doubt that today’s U.S. Republican Party is “a minority determined to rule alone.” Though more people voted for Hillary Clinton than for Donald Trump to be President in 2016, and more people voted for Democrats than for Republicans to be in the House of Representatives in 2012, that didn’t matter because the Republicans have been so good at exploiting the anti-democratic features the Founding Fathers built into the U.S. Constitution. The framers of the Constitution were openly distrustful of democracy, and they set up a system in which members of the House would be the highest-ranking federal officials chosen by direct election — and even those “elections” would be restricted to white male landowners.
The framers not only created the Electoral College to keep voters from electing the President directly, they set up a Senate that represented each state equally, regardless of population, and said it would be state legislators, not voters, who elected Senators. That changed in 1913 with the passage of the 17th Amendment, but quite a few Tea Party members in the early 2010’s actually urged that be repealed and legislators, not voters, be given back the power to choose Senators. More recently, this demand has been taken up by the powerful and influential American Legislative Exchange Council (ALEC).
Given how totally Republicans have out-organized Democrats in taking control of state legislatures and governorships, according to John Nichols in The Nation, if implemented now this would produce a Senate with 64 Republicans and 36 Democrats instead of the current 52-48 split. (See Before the 17th Amendment U.S. Senate seats were openly bought and sold through campaign contributions to key legislators — Leland Stanford (R-California), the Donald Trump of the 19th century, purchased a Senate seat for which he was outrageously unqualified — and that’s why progressive activists at the time pushed for direct election.
Even if the 17th Amendment remains in force, the equal apportionment of Senators to each state regardless of population is fundamentally undemocratic. The framers probably thought it was a compromise they could live with because at the time the Constitution was ratified in 1789, the most populous state, Virginia, had nine times the number of people as the least populous, Rhode Island. Today the most populous state, California, has 250 times as many people as the least populous, Wyoming. So not only was the Senate an undemocratic institution from the get-go, shifts in population and particularly the increasing urbanization of America has made it horrendously more undemocratic over time.
The Republicans’ political successes at the state level have been key to their ability to seize control of the entire federal government even though they remain a minority of the electorate. The Constitution gives state governments virtually total control over who may or may not vote. The great amendments that extended the franchise — the 15th, which (at least on paper) banned discrimination against people of color; the 19th, which extended the vote to women; the 24th, which abolished the poll tax; and the 26th, which lowered the age of voting eligibility to 18 and made it uniform nationwide — were all framed as specific limitations on the otherwise absolute authority of state legislatures and governors to determine who may or may not vote.
The Constitution also gives state legislators power to create the districts for House members as well as the state legislatures themselves. Republicans have used this power in recent years to do ever more precise gerrymandering to make sure that, no matter how many votes Democrats get, it will be virtually impossible for them ever to take back a House majority. And the control the Constitution gives state governments over who does and doesn’t have the right to vote is increasingly being used in Republican-dominated states to make it as easy as possible for people likely to vote Republican (older people, affluent people, white people) to vote — and as hard as possible for people not likely to vote Republican (younger people, poorer people, people of color) to vote.
During Barack Obama’s Presidency a lot of Democrats spoke confidently that their party would soon become an unassailable majority in American politics because of so-called “demographic changes” — a younger population with a lower total percentage of whites — that were supposedly going to make them the majority party over time. The Republicans responded, not (as some Republicans suggested they should) with a campaign to reach out to younger, less affluent and non-white voters, but through a concerted campaign to make sure the electorate stayed dominated by older, better off whites even as the overall population became poorer, younger and more ethnically diverse.
People who criticize President Trump’s so-called “Election Integrity Commission” as a creature of his paranoid belief that he would have won the popular vote against Hillary Clinton if it were not for the “millions of illegal votes” cast for her, as he’s claimed in his tweets, are missing the point completely. The Election Integrity Commission, chaired by Vice-President Mike Pence with Kansas Secretary of State Kris Kobach as vice-chair and former Ohio Secretary of State Ken Blackwell as a member, is actually designed to implement nationwide strategies by which Pence, Kobach, Blackwell and other Republican governors and secretaries of state have turned their states “deep-red” Republican.
These include onerous photo ID requirements, setting up more polling places in affluent areas and keeping them open longer (while cutting back polls and closing them sooner in less well-off communities, including communities of color), eliminating early voter registration and so-called “motor voter” registration, restricting the ability of voters to seek help casting and turning in their ballots, and expanding both the number of crimes for which your right to vote can be taken away and the length of time a criminal conviction will cost you your right to vote. One particularly blatant example of the real purpose of voter ID laws was provided in Texas, whose law says that a student ID can’t be used as legitimate proof of identity at a polling place — but a permit to carry a concealed weapon can.
In addition, the Election Integrity Commission has engaged in outright voter intimidation through their sweeping demand for private personal information, including partial Social Security numbers, on every registered voter in America — which has led voters in Colorado, one of the states that isn’t resisting these demands, to ask that their names be taken off the roles. (See In other words, the Trump administration is sending Americans a message: you can have the right to vote or you can preserve the privacy of your personal information. You can’t do both.
Restrictions on people’s right to vote and shrewd exploitation of the Constitution’s anti-democratic features are just two elements in a multi-faceted strategy by the Republican Party to achieve what President George W. Bush’s chief strategist, Karl Rove, called “full-spectrum dominance” of American politics. One of the most bizarre aspects of the strategy is that even the people the Democrats are able to elect are being frozen out of the decision-making process as much as possible. Recently, Congressmember Jerrold Nadler (D-New York) was interviewed on MS-NBC after Attorney General Jeff Sessions appeared before the House Judiciary Committee, of which Nadler is a member — but Sessions would only answer questions from Republicans on the committee, not Democrats.
Not only did Mitch McConnell convene an exclusively Republican committee to write the U.S. Senate’s proposal to “repeal and replace” the Affordable Care Act, President Trump himself expressed his contempt for the very idea that the other political party in the Senate should be allowed to have anything to do with it. When preliminary vote counts on the BCRA showed four Republican Senators against it, Trump said publicly that “48 to 4” sounded like a really big majority to him. And when the Motion to Proceed on health-care legislation passed July 25, Trump was even more blatant, saying that the margin of passage was “51 to whatever.” Given Trump’s famous statement about journalist Megyn Kelly that during her tough questioning of him on a 2015 Republican candidates’ debate that “she had blood coming out of her eyes, or her wherever,” if I were a Democratic Senator I’d have a pretty strong feeling that the President of the United States has just compared me to menstrual blood.
As I’ve pointed out in previous posts, Donald Trump does not want, and never has wanted, to be the powerful but still constitutionally limited president of a democratic republic. He wants to be a dictator. His response to the allegations that members of his campaign colluded with Russian officials to “fix” the 2016 election in his favor has been to denounce it as a “witch hunt,” fire the FBI director leading the investigation, threaten to fire the special counsel as well as his own Attorney General, and publicly muse over the possibility that he could simply use the Presidential pardon power to get himself and all his aides off the hook.
Trump’s dictatorial nature is shown in his far greater comfort level in international meetings around other dictators — particularly ones like Russia’s Vladimir Putin, Turkey’s Recep Tayyip Erdogan, the Philippines’ Rodrigo Duterte, Egypt’s Abdel Fattah el-Sisi, Hungary’s Viktor Orbán, and Poland’s Andrzej Duda, who took power in at least nominally republican countries and turned them into authoritarian states, as I’m convinced Trump wants to do to the U.S. — in international meetings than democratically elected leaders like Germany’s Angela Merkel or Australia’s Malcolm Turnbull. It’s also shown in the extraordinarily expansive portfolio he’s assigned to his son-in-law, Jared Kushner, who got to issue his public denial of collusion with Russia from a podium with the White House logo on it, in front of the White House itself — a clear public message that Trump wants Kushner to succeed him as President when age and the 22nd Amendment term him out in 2025.
Trump’s entire life has been one in which, by sheer grit, determination and utter unscrupulousness, he has survived crises which would have brought down a lesser mortal. He did it in 1991, when his Atlantic City casinos went bankrupt and the banks who’d lent him the money to build them were about to foreclose on him — only he convinced them that the casinos would be more lucrative with his name on them than without it. He did it over and over again during his Presidential campaign, when he recovered from disasters (including his taped comments that virtually boasted about raping women and his open incitement of violence against protesters at his rallies, as well as his boorish, almost unhinged treatment of Hillary Clinton during the debates) that would have sunk the campaign of almost anyone else, and won a stunning upset from which his political opponents are still haplessly reeling.
And as Donald Trump marches America ever closer towards a personal dictatorship — and the Republicans in Congress continue to enable him — who’s going to stop him? Despite his much-vaunted reputation for “integrity” and his public statement that it was time for the Senate to return to “regular order” and create a health bill through open debate in the committee process, when push came to shove Senator John McCain (R-Arizona) got behind Trump’s agenda on July 25 and voted not only for the Motion to Proceed but also for the BCRA, the very bill created by the secret process he had denounced in his floor speech. Like a good little “democratic centralist” soldier in a Leninist “vanguard party,” McCain put party, not country, first and voted for a process and a bill he said he abhorred.
The Republicans in both the House and Senate are, with a few exceptions, deeply committed to a Libertarian ideology that wants to wipe out all social welfare programs and all civil-rights protections, as well as all restrictions on corporations’ ability to exploit workers, consumers and the environment. (Ayn Rand was bitterly anti-environmentalist; she literally believed the power of capitalist entrepreneurs was so great it could change the laws of nature, and her hatred of environmentalism got passed on to the current Republican Right and is yet one more difference between the American and European Right.) They will stick solidly behind Donald Trump as long as they think he can still be of use to them in pushing the end of America’s welfare state and the end of all restrictions on business; only if he loses enough credibility with the Republican base for them to think he’s not of use to them anymore, and President Mike Pence would be, will they abandon him and impeach him or force his resignation.
During the July 25 telecast of Chris Matthews’ Hardball on MS-NBC, Matthews asked one of his three-person panels to predict whether President Trump will be able to serve out his full term. All three members said he not only will, he’ll be re-elected and serve out a second full term as well. Indeed, it’s quite possible that the Trump regime will last a full quarter-century: President Donald Trump, 2017-2025; President Jared Kushner, 2025-2033; President Ivanka Trump, 2033-2041. And at the end of that time the U.S. will be a profoundly different country from what it is today, resembling the U.S. in the 1880’s (the real period Trump, like Ayn Rand, thinks was when America was “great” and to which he wants to return us so we can be “great again”): total dominance of the political system by the rich, second-class citizenship for working people and people of color, environmental devastation, women back in the kitchen, people of color back at the back of the bus, Queer people back in the closet and a Hunger Games-style economy in which the overwhelming majority of people starve (and with little or no access to health care) while a handful of aristocrats feast.