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Trump’s vision for American health care, explained by his budget

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Democratic presidential candidates have spent years building a new vision of American policy, one where a lot more of us get our health insurance from the government.

I see President Trump’s newly released budget as his counterproposal to all that. It envisions a really different future, one where government-run health care shrinks — and public programs become more difficult to sign up for.

Here are some key health policy features of the Trump budget (you can read the full thing here):

  • Repealing Obamacare and replacing it with Graham-Cassidy. Those who followed the Obamacare repeal debate closely will certainly remember the replacement proposal from Sens. Lindsey Graham (R-SC) and Bill Cassidy (R-LA). As I’ve written previously, this plan would allow insurers to discriminate against those with preexisting conditions and significantly cut insurance subsidies for low- and middle-income Americans.
  • Cutting $845 billion from Medicare. These are some pretty significant cuts that are already getting a lot of attention. To be honest, I don’t see them as the most notable part of this budget. As Axios’s Sam Baker points out, a big chunk of these Medicare cuts are ones that have bipartisan backing — so much so that they the Obama administration proposed them in years past. Even Obamacare cut Medicare by $716 billion — something Republicans continually brought up in the 2012 election. At the same time, there are certain changes in the budget that could have a negative impact for patients: for example, the budget proposes requiring prior authorization for certain medical procedures that are likely to be the subject of fraud — which could make it harder for seniors to get care.
  • A nationwide work requirement for Medicaid. Republican governors in places like Arkansas and Wisconsin have recently begun requiring their Medicaid enrollees to work, go to school, or be job-searching in order to qualify for health benefits. The idea is to use the medical coverage as an incentive to get more Americans to join the workforce — but early data (primarily from Arkansas) suggests that these types of work requirements can be difficult to comply with, and people who really rely on their Medicaid plans are starting to lose coverage. The Trump budget would create a nationwide Medicaid work requirement that would save the government an estimated $245 billion — cuts that would likely come from fewer Americans getting coverage through the program.
  • Bigger copayments in Medicaid too. The Trump budget proposes “additional flexibility around benefits and cost-sharing, such as increasing copayments for non-emergency use of the emergency department.” We know from a lengthy body of health policy research that when you have higher costs associated with health care, patients cut back on their doctor trips — both the ones are needed and those that aren’t quite so necessary. You’d expect that a change like this might cut back on some unnecessary ER visits, but it’s also going to deter patients from seeking emergency care in cases where they really need it.
  • No more premium-free Obamacare plans. In many parts of the country, low-income Americans qualify for “zero premium” insurance plans: health coverage where the entire premium would be covered by their government tax credit. The Trump administration wants to put an end to that. In order to “increase consumer engagement,” the White House proposes that “all subsidized individuals that purchase health coverage on the Federal Exchange to contribute something to their healthcare coverage.” How exactly this would happen is not made clear in the budget proposal.

Higher copayments, work requirements, no more zero-premium Obamacare plans — take it all together and you create a health care system where it’s significantly harder and more expensive to go to the doctor.

There are some benefits to this type of health care system, no doubt. When fewer people get public coverage — and those remaining people go to the doctor less because their copays are higher — then the government spends less money on health care. So if your biggest goal is reducing the deficit, this plan would check that box.

But those spending cuts come with some undeniable human consequences. Bryce Covert recently wrote a compelling piece for the Nation, exploring the human consequences of Arkansas’s new Medicaid work requirement. One of the things she finds is that those who are having trouble keeping up with the bureaucracy of the work requirement — who are working but haven’t properly reported that to the state — are struggling to hold on to their coverage.

What we’re seeing right now is two really different visions of the future of American health care. We have one from the Democrats that envisions a robust health care system, one without any copayments or deductibles. There are still holes in that vision — namely, how to pay for such a generous version of American health care — and I’d guess these proposals get revised to include some type of cost sharing as they work their way through Congress. All that being said, what Democrats are offering right now is a clear vision of how they think medical care should be in the United States: easily affordable and accessible to all Americans.

The other vision offered today by the Trump administration lays out a future where the government spends less on health care — and, as a result, vulnerable populations get less medical care.

This vision does not come with the difficult “how do you pay for it” questions that plague any Medicare-for-all proposal. But it comes with its own big question: namely, how are low-income Americans going to get by in a country where they get a lot less help affording basic medical services?

The answer to that question is probably that they don’t get by very well. The future the Trump budget lays out is one in which richer Americans can do just fine buying their own health care. There aren’t big changes for those who get insurance at work, as higher-income Americans typically do. But it’s a future where, if you’re poor, seeking care gets a lot harder.

This story appears in VoxCare, a newsletter from Vox on the latest twists and turns in America’s health care debate. Sign up to get VoxCare in your inbox along with more health care stats and news.

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Look at How Much “Game of Thrones” Characters Have Changed Over 8 Seasons

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During the summer of 2019, the final season of Game of Thrones aired. The show had gone on for almost 10 years which is a long time not only for the characters but also for the actors who portrayed them.

Bright Side is remembering what characters looked like in the very first episodes of the groundbreaking series and is comparing them to what they look like in the final season of the show.

1. Cersei Lannister

2. Jon Snow

3. Tyrion Lannister

4. Daenerys Targaryen

5. Sansa Stark

6. Arya Stark

7. Jorah Mormont

8. Varys

9. Jaime Lannister

10. Sandor Clegane

11. Brienne of Tarth

12. Samwell Tarly

13. Davos Seaworth

14. Theon Greyjoy

15. Brandon Stark

Did you watch Game of Thrones? Did you enjoy season 8? Tell us in the comment section below.

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Baltimore’s ransomware attack, explained – Vox

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Thirteen bitcoins are standing between the city of Baltimore and many of the services and processes its citizens rely on after hackers seized thousands of government computers at the start of the month. The ordeal has been going on for two weeks, and there’s no clear end in sight.

Here’s what’s happening: On May 7, hackers digitally seized about 10,000 Baltimore government computers and demanded around $100,000 worth in bitcoins to free them back up. It’s a so-called “ransomware” attack, where hackers deploy malicious software to block access to or take over a computer system until the owner of that system pays a ransom.

Baltimore, like several other cities that have been hit by such attacks over the past two years, is refusing to pay up. As a result, for two weeks, city employees have been locked out of their email accounts and citizens have been unable to access essential services, including websites where they pay their water bills, property taxes, and parking tickets. This is Baltimore’s second ransomware attack in about 15 months: Last year, a separate attack shut down the city’s 911 system for about a day. Baltimore has come under scrutiny for its handling of both attacks.

The ransomware attacks in Baltimore and other local governments across the US demonstrate that as ransomware attacks spread, and as common targets such as hospitals and schools beef up their online systems’ security, there are still plenty targets vulnerable to this kind of hack. It also exemplifies the conundrum that ransomware victims face: pay up and get your access back, or refuse — potentially costing much more in the long run.

What’s going on in Baltimore, briefly explained

Hackers targeted the city of Baltimore on May 7 using a ransomware called RobbinHood, which, as NPR explains, makes it impossible to access a server without a digital key that only the hackers have.

The Baltimore hackers’ ransom note, obtained by the Baltimore Sun, demanded payment of three bitcoins per system to be unlocked, which amounts to 13 bitcoins to unlock all the seized systems. The note threatened to increase the ransom if it wasn’t paid in four days, and said the information would be lost forever if it wasn’t paid in 10 days. Both deadlines have now passed.

“We won’t talk more, all we know is MONEY! Hurry up! Tik Tak, Tik Tak, Tik Tak!” the note said.

The city government is refusing to pay, meaning that the government email systems and payment platforms the attack took down remain offline. The attack has also harmed Baltimore’s property market, because officials weren’t able to access systems needed to complete real estate sales. (The city said transactions resumed on Monday.)

Baltimore Mayor Jack Young, who’s officially been in his office less than a month, said in a statement on Friday that city officials are “well into the restorative process” and have “engaged leading industry cybersecurity experts who are on-site 24-7 working with us.” The FBI is also involved in the investigation.

“Some of the restoration efforts also require that we rebuild certain systems to make sure that when we restore business functions, we are doing so in a secure manner,” Young said. He did not offer a timeline for when all systems will come back online.

The Baltimore City Council president also plans to form a special committee to investigate this latest attack and try to ensure it doesn’t happen again.

A similar attack using RobbinHood hit government computers in Greenville, North Carolina, in April. A spokesperson for Greenville told the Wall Street Journal that the city never wound up paying, and that while its systems aren’t entirely restored, “all of our major technology needs are now being met.”

More than 20 municipalities in the US have been hit by cyberattacks this year alone. And such attacks can be expensive, perhaps especially if targets say they won’t pay. In 2018, hackers demanded that Atlanta pay about $50,000 in bitcoins as part of a ransomware attack. The city refused, and according to a report obtained by the Atlanta Journal-Constitution and Channel 2 Action News, the attack wound up costing the city $17 million to fix.

Ransomware attacks aren’t new — but we’re still figuring out how to deal with them

In 2017, a ransomware called WannaCry targeted tens of thousands of computers using Microsoft Windows operating systems in more than 100 countries. Officials in the US and the United Kingdom eventually blamed North Korea for the attack. Also in 2017, corporations in the UK, France, Russia, Israel, and Ukraine experienced ransomware attacks. US hospitals were also targeted.

Here’s how Timothy Lee explained for Vox what was going on and how ransomware had become more prolific:

The basic idea behind ransomware is simple: A criminal hacks into your computer, scrambles your files with unbreakable encryption, and then demands that you pay for the encryption key needed to unscramble the files. If you have important files on your computer, you might be willing to pay a lot to avoid losing them.

Ransomware schemes have become a lot more effective since the invention of Bitcoin in 2009. Conventional payment networks like Visa and Mastercard make it difficult to accept payments without revealing your identity. Bitcoin makes that a lot easier. So the past four years have seen a surge in ransomware schemes striking unsuspecting PC users.

Some ransomware schemes are so sophisticated that they even invest in customer service, helping victims who want to pay their ransoms navigate the complexities of obtaining bitcoins and making bitcoin payments.

Since then, a number of sectors and organizations have made improvements to their security practices to protect against ransomware. But the latest Baltimore attack exemplifies what a whack-a-mole game this is: One area improves its practices and hackers just go looking for another.


Recode and Vox have joined forces to uncover and explain how our digital world is changing — and changing us. Subscribe to Recode podcasts to hear Kara Swisher and Peter Kafka lead the tough conversations the technology industry needs today.

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Cameron Russell for ELLE

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A film by Kai Z Feng of our February 2014 cover.

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