On trains, health care, and misfiring democracy

When we lived in Hungary we noticed a curious thing about their train network. Our city had about 68,000 people in it yet only had one train per day to the capital city, Budapest. If you couldn’t make the early morning direct train, to take a region train to the much smaller town of Dombovár and transfer to a high speed train the rest of the way. This only added 10 minutes of travel if you caught the right train to Dombovár, but quite a bit of unnecessary hassle.

Today, if you want to get from Kaposvár to Budapest you have three direct trains and five connecting through Dombovár for a total of eight possible trips. Meanwhile, Dombovár has 10 total trips — though some of them are quite long they’re all direct. A fact that would be less strange if there weren’t any direct trains to Budapest at all, but the fact that there are some, and all of them stop in Dombovár, suggests there could be more.

Maybe there’s really more demand for connections to the capital from a town a third the size of Kaposvár, but when I asked my Hungarian co-teacher about it, I was told that Kaposvár used to have many more lines to Budapest but voted for the wrong party in the last election and lost their direct connections. I take most things that particular teach told me with a grain of salt, but assuming it’s true, punishing people because they didn’t vote for the majority seems like an anti pattern for a democratic society.

That’s essentially what the GOP is trying to do to with this most recent health care bill, the so-called Graham-Cassidy Amendment. Numerous analyses of the bill have shown it stands to benefit the states that chose not to expand medicare — giving them more money — at the expense of those that opted for the expansion under the Affordable Care Act. What’s worse is that it appears the leadership — the amendment’s authors especially — are offering deals to exempt Senators whose states will be adversely affected in attempt to sway their vote for the bill. The guise of a policy reason for this is to not over-burden states with low population density:

Beginning on page 95, the bill has a provision that exempts low-density states whose block grants either decrease or stay flat between 2020 and 2026 from the Medicaid per capita cap. Under that scenario, Alaska and Montana would be exempted from the funding cap that applies to all other states during that period.

If only Montana and Alaska are exempted, where are they drawing the line on population density? Let’s look at 13 most sparsely populated states, how they fare, and how they voted in 2016 (source):

  1. Alaska: exempt — R
  2. Wyoming: 2% cut — R
  3. Montana: exempt — R
  4. North Dakota: 8% cut — R
  5. South Dakota: 45% increase — R
  6. New Mexico: 15% cut — D
  7. Idaho: 27% increase — R
  8. Nebraska: 13% cut — R
  9. Nevada: 8% cut — D
  10. Kansas: 61% increase — R
  11. Utah: 30% increase — R
  12. Oregon: 32% cut — D

The line is apparently 10 people per square mile. Except, for some reason, Wyoming. Shutting out those other states with similarly difficult rural healthcare problems. There may be roads to all the towns in these other states but that doesn’t mean their rural communities aren’t hard to reach. They’re in the desert, at elevation, or hundreds of miles from the nearest major city. If the states have to close rural health care facilities because of lost medicare funding, lives are at risk. The population density argument is ruse. It’s not about saving states with disproportionately hard to reach residents, it’s about sparing Republican senators in hard-hit states who are resistant to voting for the amendment.

Democratic governments should govern for the people and by the people. That means our representatives should act in the interest of their constituents for the good of the country — not subject the opposition to vindictive consequences. Furthermore, the 14th Amendment to our Constitution guarantees equal protection under the law. If the law has special provisions for certain sets of people who happen to vote the right way, that’s not equal protection. It’s bad enough this amendment administers benefits so unevenly, to add special protections for senators to get them to vote for it makes it unconstitutional.