In the previous post, there were a couple of good questions about the Arkansas Medicaid “private option” waiver. The big one is would the Bronze plans on the Exchange be effectively useless to someone making 75% of FPL as they could not even look at the co-insurance and deductible as plausible payments.
Here is a bit more news on the Arkansas waiver (amazing what happens when one read’s the application!)
Arkansas will be submitting a SPA in addition to the submission of waiver requests for this Demonstration which includes eligibility limits for the newly covered population, updated cost-sharing requirements and the state’s selection of an ABP. Consumer cost-sharing obligations under the Demonstration will be identical to those under the State Plan for all individuals receiving the ABP. The SPA describing the ABP will include the cost-sharing design for all individuals receiving the ABP. As will be described in the SPA, Private Option beneficiaries with incomes below 100% FPL will not have cost-sharing obligations in year one of the Demonstration; Arkansas plans to submit amendments to the waiver to implement cost-sharing for Demonstration participants with incomes from 50-100% FPL to be effective in years two and three of the Demonstration. Individuals with incomes of 100-138% FPL will be responsible for cost-sharing in amounts consistent with both the State Plan and with the cost-sharing rules applicable to individuals with comparable incomes in the Marketplace. . For individuals with income between 100-138% FPL, aggregate annual cost-sharing will be capped at 5% of 100% FPL ($604 for 2014). Providers will collect all applicable co-payments at the point of care. QHPs will monitor Private Option beneficiaries’ aggregate amount of co-payments to ensure that they do not exceed the annual limit.
Let’s break it down.
- Year 1, people under poverty line won’t have any cost-sharing.
- Year 2 and 3 people under poverty line will have some cost sharing.
- People over poverty line but MA eligible will have cost sharing up to 5% of federal poverty line.
§ 1902(a)(17): To permit the State to provide different delivery systems for different populations of Medicaid beneficiaries. The State is not requesting a waiver of comparability with respect to benefits, eligibility, or cost-sharing.
Earlier in the waiver, Arkansas is making a big deal about dealing with churn as its justification for the “private option:”
Continuity of coverage – For households with members eligible for coverage under Title XIX and Marketplace coverage as well as those who have income fluctuations that cause their eligibility to change year-to-year, the Demonstration will create continuity of health plans and provider networks. Households can stay enrolled in the same plan regardless of whether their coverage is subsidized through Medicaid, CHIP (after year one), or Advanced Premium Tax Credits.
I think this is a good policy justification for this option. We know that income variance is high at the bottom of the economic scale. Some people could have a good couple weeks of overtime at working that knock them out of one program to another, or someone who had just missed qualifying by $22 a week now qualifies after they lost the Thursday morning shift. People shifting between dissimilar plans and dissimilar networks and different providers are a problem because the continuity of their care (to use a highly technical term) sucks.
sparrow
I posted this at the end of the last thread, so I’ll re-post here. Is my understanding correct?
sparrow
@Richard Mayhew: Thanks. So in the second case, you’re on a 30% coinsurance plan with a relatively high out-of-pocket max, right? That’s kind of what I wanted to verify. I think it’s still better than nothing, of course!
low-tech cyclist
Richard – thanks for taking the trouble to read through this stuff for the rest of us, and show us what it means.
Elizabelle
Richard: I am really glad you are here. Great threads.
Today is T minus one, bitchez!
JPL
According to the Borowitz Report: FOX NEWS: OBAMA IN PLOT TO FORCE AMERICANS TO LIVE LONGER
Although the article in is jest, twenty-seven percent would believe it.
Elizabelle
@JPL:
The problem is, the burden of paying for those long-lived wankers now falls squarely on Mr. John Q Teapartier, in his Medicare scooter. Shouldering healthcare for others, although he has paid for every penny of benefits he himself receives.
The horror. A first world country with more equitable health insurance coverage. F*cking totalitarians.
aimai
@Richard Mayhew: That seems pretty good, to me. Admittedly 600 dollars is a huge amount if you have nothing. But 600 dollar after which you get actual medical care, fully covered, for cancer? I have to believe that there will be people and charities that will step in to make that happen. You can raise that kind of money with a charity supper and peopole have been forced to try that route with bills of hundreds of thousands of dollars. It is still better than no insurance or a hugely high deductible. I’f I’m grasping what you are saying.
JPL
@aimai: Should someone profit from someone’s cancer? I agree that it’s a small sum but those small sums add up to a nice profit for the insurance overlords. You are right though, it’s better than nothing.
negative 1
@aimai: One million times this. There are certainly issues to work out, but finding ways to fund $600 per person for a vulnerable group is certainly a surmountable problem. Finding ways to give a group unknown amounts of money is not. I think this is what people refer to when they say there might be some adjustments after initial rollout but give it time.
jayackroyd
You do realize, Richard, that this series of posts is making a really strong case that it was a really bad idea to retain profit making insurance companies as the payer mechanism.
The contrast between the systems in the UK or Canada is really pretty astounding.
Richard Mayhew
@jayackroyd: No dispute
Richard Mayhew
@JPL: When the other choices present are eat shit and die, or here is some morphine, now go die quietly, a $600 co-pay (max) is a far superior alternative
Violet
I caught something on the TV news this morning that the Republicans are adding something to their hostage-taking demands that all Congressional and White House staff, and maybe Congressmen and Senators but I wasn’t clear on that, would be required to buy health insurance on the new exchanges. Does anyone know anything about that? Does that mean they’d take away health insurance under federal employee status for those individuals? WTF?
RaflW
@JPL: I think this misunderstands the tectonic shift of A.C.A.
Under the nearly extinct model, ins co’s made profit via cancer thru taking premiums for years, then canceling you when you got cancer, through any means possible.
Under A.C.A. The ins co’s make money when healthy people enrol and stay healthy.
This creates the mandate that the right hates because its a mandate on private behavior and the left hates because its a mandate for profit. (Unless you live in an enlightened state like MN where ins co’s are by law nonprofits)
But as we know pooled risk and the distortion caused by guaranteed issue w/o a mandate means the whole kludge* of A.C.A. fails if the mandate is gone (or delayed).
*The Evonomist had a great item about America’s Kludgiest Kludge (aka A.C.A.) the other day.
Yatsuno
@jayackroyd: I love how you think that is some sort of accident. Why do so many assume ACA is the endgame?
Amir Khalid
“… when one read’s”? “… when one read’s“? The horror! Fetch me the smelling salts!
(Sometimes, when the topic is particularly specific to the US, this non-American commenter must make do with a punctuation rant.)
Violet
@Amir Khalid: How does health insurance work in Malaysia?
RaflW
@Violet: requiring Congress and their staff to buy on the exchanges was in the passed bill.
What’s in the GOP ransome note is removing the ability of the govt to pay a portion of the premium for the employee. It’s a pay cut for Congress (and in particular to screw staffers).
Violet
@Yatsuno: Agreed. You have to start somewhere. ACA is a good start. It’s not perfect. It’s not the pony AND unicorn AND rainbow AND chocolate candy mountain all rolled up into one, but it’s a start. It covers a lot more people than we had covered before and it eliminates some of the horrors of our old system, like the pre-existing conditions refusals. It’s still allowing too much profit on people’s illnesses, but it makes that sort of thing a lot more obvious and puts controls on costs and increases. I think it will be improved over time. You have to start somewhere and ACA is a lot better than nothing.
Violet
@RaflW: Ah, okay. Thanks. That seems like it would be illegal. Why would they be the only ones not eligible for subsidies. The elected reps–sure, screw ’em.
Yatsuno
@Violet: Per teh Wiki, public-private split similar to Australia. Couldn’t find when it was founded but possibly from independence from Britain since the NHS would have existed then. Amir is well-cared for I think. :)
@Violet: It will be like every other expansion of our safety net: start smallish, then expand slowly until it achieves a greater end goal. A lot of the world’s public pension systems are based upon SS now, so once single payer takes root (thank you VT!) it will be a matter of time from there.
RaflW
I should add that I too would prefer single payer, not for profit insurance for all. The urge/need to protect the ins companies in building A.C.A. was a huge concession.
For pure simplicity and cost savings, I think Medicare for all makes much more sense.
And it’s not like Medicare obviates all private insurance. A LOT of Medicare customers buy supplemental plans.
I’d like to see a gradual lowering of Medicare eligibility age as a a way to progressively strangle A.C.A. But then, I’d also like a national high speed rail network and a tax on suburban sprawl.
Medicare for all has maybe a 5% better chance than national HS rail … and America may never end it’s suburban love. Oh well, a liberal has to have dreams.
PhoenixRising
Right, so a couple of things about that, on my 2nd cancerversairy:
1) That deductible amount was sold (to me, before ACA) as ‘your deductible’. But it turned out that $n was $n times 3, because that’s the ‘family’ deductible and our kid was on my insurance because as the healthy person I could buy insurance at all.
2) After we spent ($n times 3), insurance started paying 80% until ‘my portion’ of cancer had cost me ($n times 5). This is an out of pocket limit.
This is OT, except that it’s pretty important that folks who have been uninsured, or underinsured, but healthy–who therefore don’t know how health insurance works–to have a realistic sense of just how many bake sales we’re talking about here.
I have a manageable type of cancer, not expected to be cured but I’m expected to live 15 more years, at a probability of .62; this means that ACA is saving my child’s college funding, my house and my retirement should I be in the 38% who die of something else…later. I’m grateful, and I want everyone who’s sick to have fewer worries. Realistic expectations play a role in that.
LittlePig
The sad truth is there is a still a lot of irrational pushback. I had to talk my step-sister, living well below the poverty line and living in subsidized housing, into looking into it. The problem? No, not the Rush Limbaughs and Glenn Becks, though that was my niece’s father’s issue with it. She was brought up not to take charity from black people, period full-stop.
My native Arkansas has really disappointed me on the this whole having a black-complected President (especially the Romney vote. Arkansans voting for a Mormon. Step-sis couldn’t go that far;”he’s not really a Christian”). A lot more people have gone stark raving mad than I expected. These folks would vote against a sunny day if the President supported it.
Violet
@LittlePig:
I keep wishing the President and Michelle would start a campaign to support breathing. Republicans would reflexively be against it. Easy way to rid ourselves of the meddlesome Republicans.
WereBear
There’s an important point here that I don’t see discussed much:
Having insurance means you get treated.
Showing up in an emergency room uninsured means you won’t die. And that’s all.
Crucial points that can give you a meaningful life, afterward, will be checked off. IF you have insurance.
That is huge.
sparrow
@WereBear: Thank you, that was exactly what I was trying to get at.
aimai
@JPL: Even national health insurance is CO-INSURANCE. A national health care pool is just very very big and the cancer care is paid for by taxpayers and businesses. All the citizens are chipping in to pay for each other’s care. You might even argue that the hospitals and the doctors and nurses are “profiting” off the care of cancer patients because they get paid to do their jobs. A hard and fast line between for profit and not for profit isn’t really the best way to think about this. At any rate–health care is going to cost and cost a lot. The only question is how can we bring everyone into a system of paying into the pool so that everyone can benefit in the cost sharing.
Matt McIrvin
@Yatsuno: Because our political system is terminally broken. Where’s the mechanism for it ever getting better?
JPL
@aimai: You and Richard are both correct and your comment on someone always benefiting is true. My concern is keeping the costs low. It will take time and we are at a good starting point. GA isn’t expanding medicaid and one of the local news channels, did a good job explaining that some are left out of the program. They don’t qualify for medicaid and their meager salary doesn’t qualify for adequate subsidies.
jayackroyd
@Richard Mayhew: Well, at least we got bipartisan cooperation by incorporating Republican market based approaches into the program. We knew it would add complexity, but it was worth it to get to the middle ground.
WereBear
If Dems in such states don’t run on that next year, they deserve a clue-by-four upside the head.
Amir Khalid
@Violet: @Violet:
That Wikipedia article describes the availability of healthcare here quite well. As for how it’s paid for — employers with 15 on staff or more are required to provide outpatient care, meds included, for employees and eligible dependents (i.e. spouse and minor kids). This is usually supplemented with privately purchased health insurance for things beyond that. Some larger employers go beyond this and provide hospitalisation benefits too. (Mine paid for my angioplasty at a private hospital.) There was talk a year or so ago (i.e. ahead of the last elections) of improving health insurance options, but not much has happened since.
Richard Mayhew
@jayackroyd: Jay — going single payer in 2009 — does that get Baucus, Nelson I or Nelson II, Landrieu, Pryor or Bayh voting for it? Same question in the House, were there 218 for single payer, or even an approach to get 218?
I am pretty damn sure neither 51 nor 218 were there or were gettable in 2009/2010 for single payer.
If the choice was nothing or PPACA, I’ll take PPACA 8 days a week.
Raven on the Hill
This is hopeful. It’s still a boondoggle, but at least it’s one that’s going to fall less on the poor.
And a big shout-out to the HHS/CMS bureaucrats who are genuinely looking out for them!
Mnemosyne
@WereBear:
And, in states where the Medicaid expansion was accepted, there is now an automatic assumption that someone without insurance qualifies for Medicaid, and they’re auto-enrolled. That’s a HUGE and important change, because it will get people who had not yet signed up onto the rolls and into the system so they can get the care they need.
ETA: Auto-enrolled when they show up at the ER, that is.
I do think that Arkansas has a good point about people who are right on the income border getting bounced on and off Medicaid every year and how this waiver could give them more stability and a better idea of which doctors they can see from year to year. If it works out, it might be a good solution for rural states where they have a lot of people who are frequently in danger of losing their healthcare if they make “too much” money — it could be a good way to transition them into having it all the time and not having to worry that having a good year on the farm is going to mean they lose their health coverage.
mclaren
No, the plan is the problem.
Any health care plan that depends on income is destructive. Any health care plan that depends on income kills people. Any health care system that depends on income wrecks the country that tries to implement it, and ultimately collapses of sheer unworkability.
Ruckus
@aimai:
You brought up a great point that profit and non-profit is not the entire answer.
We should remember that a non-profit can make money, it just in theory has to be re-invested in the business. At some point in time. Executive salaries and expenses are not limited by being a non-profit.
Making insurance companies spend 80% of premiums is a controlling factor and is one reason that policy costs are coming down. A huge additional pool of people/subsidies that will pay with expected small costs is another.
aimai
@JPL: There are a lot of people who simply could not buy health insurance at all prior to Obamacare, they will be better off. The legislators tried to bring as many people as they could into the system by paying states to expand medicaid eligibility but were thwarted by the Supreme Court making this optional. This is a hugely complicated system but the one thing you can say is that although a slice of a slice of people are still going to be left out of coverage, and coverage itself is going to be expensive and not “free” to the user, that almost everyone is going to be better off than they were before. Someone who is too wealthy to qualify for medicaid now, and too poor to afford the exchanges is already someone who could not access health insurance prior to Obamacare. They will be no worse off. They won’t be better off right this minute but at least under the system the incentive is to get more and more people covered and, once they are covered, they can’t be terminated or left uncovered.
For fuck’s sake we have had the system up and running in MA for 7 years. I have heard zero horror stories.
aimai
@mclaren: Oh the “no bread is better than half a loaf” caucus is heard from.! Of course it is preferable that everyone who does not have employer sponsored health insurance die than that a parallel system that enables people to buy their insurance and pool their risk without employer input be created. That makes perfect sense.
Richard Mayhew
@mclaren: How do we get a system that is income agnostic in this country? Please tell me how to get 218, 51, 1 and 5 and I’ll be right behind you in pushing for it — till then, I’ll take improvements over the status quo when and where I can find them.
jl
The post lost me a bit at the end, and sorry don’t have time to read all the comments though. Will have time later.
in previous thread, Mayhew said the plan was not efficient, but and OK inefficient gimmick that looked ‘convervative’ and didn’t mess with poor beneficiaries too much.
Now he finds some good points to the plan, one of which is that the premium help with continuity of care that occurs in existing system. That is good, since continuity of care is one of the most difficult things to achieve in a system no matter what health system. The US does less well than most for lower middle, working and poor classes. I will time to go so source material and decipher each line later.
But is my basic impression correct?
mclaren
@aimai:
No, that’s 600 dollars as the entry to a continual bleeding. Thousands upon thousands upon thousands of dollars for prescription drug “co-payments.” Thousands upon thousands upon thousands for special medical procedures (like getting your temperature taken in hospital) mysteriously not covered by medicare. And so on.
The American medical system is a gigantic scam. There is no such thing as low-cost care. “Low-cost” means “we still dun you for tens or hundreds of thousands of dollars for prescription drug co-pays, necessary medical procedures which don’t happen to be covered under the plan, and basic necessities like a morphine pump for terminal cancer that aren’t included in “basic care.”
Just think of the American medical system as hell. When you’re in hell, is there any relief from the torture? Ever?
Please.
Johnathan
FYI, the Arkansas Waiver actually calls for enrollees to receive a Silver plan, but with the entire premium paid (using what are ultimately federal dollars) by Arkansas Medicaid. In addition, just as those from 138-250% FPL receive CSR (Cost Sharing Reductions) paid by the Exchange that reduce their copays, deductibles, and total out of pocket limit, those under the Waiver will have a similar CSR payment made by Arkansas Medicaid that will reduce cost sharing to these levels: 0>100% FPL – no cost sharing, 101 > 138% FPL, cost sharing at standard Medicaid copays, deductibles, etc. with an out of pocket limit of 5% of income. In addition, Arkansas will provide “wrap around” benefits for things that private insurance does not cover which Medicaid must, by law: Non-emergency medical transportation (bus pass, cab ride, etc. if someone does not have their own transportation to a doctor appointment) and EPSDT (Early & Periodic Screening, Diagnosis, and Treatment – basically extra benefits to keep kids healthy).
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/ar-private-option-ca.pdf
Richard Mayhew
@mclaren: McLaren — we get it, you want single payer NHS style last week… how do we get there?
Mnemosyne
@Richard Mayhew:
Even the NHS took over 30 years to be created from the first notion of universal coverage to the original NHS legislation passed in 1948, though mclaren loves to pretend otherwise.
Richard Mayhew
@jl: Correct — there are two upsides to the private option plan. One, it is a politically acceptable expansion of Medicaid for a quarter million people in Arkansas while a conventional expansion would not have passed. The second is that it does have a good chance of dealing with income qualification churn by taking a look at income once a year instead of quarterly or more frequently.
Overall, I think this “private option” plan will be, from a policy evaluation perspective efficient at getting people covered but inefficient at doing so. I think the program design does resolve one problem (churn) but a fairly high cost compared to other alternatives (best alternative would have been a waiver requesting income verification once a year for traditional MA)
ruviana
@Amir Khalid: Rant away! Those of us who fight for decent punctuation need all the help we can get, even if it isn’t as life-and-death-making as decent health care.
mclaren
@Mnemosyne:
The first legislation in America aimed at creating nationalized single-payer health care was offered up by Harry Truman in 1948.
The AMA killed it.
So it’s been more than 65 years now between the first bill to create nationalized single-payer health care in America, and we still don’t have it.
How long should we wait, Mnemosyne? 100 years? 200 years? 500 years? 1000 years? 10,000 years? Should we wait until the mountains wear away and the seas dry up and the sun expands until earth’s atmosphere boils away into space?
How long should we wait?
Source: “Time to yank the AMA’s license,” The New York Observer, 16 June 2009.
Source: “A Brief History of Universal Health Care Efforts in the U.S.,” Physicians for National Health Care website.
Mnemosyne’s lies and scams prove typical of the corporate courtiers and far-right asskissers who frantically try to deflect the progressive agenda with the old con job, “It’s going to take some time.”
When the Civil War loomed, regressive thugs like Mnemosyne chimed in to explain that the time was not yet to free the slaves: “It’s going to take time.” Code words for WE’LL FIGHT TO THE DEATH AGAINST EVEN THE MOST MINIMAL REFORMS, BUT WE WON’T BE HONEST AND SAY THAT.
When the Wobblies agitated for the 8-hour working day, corporate serfs like Mnemosyne warbled, “It’s too soon. We have to go slow. This is going to take time.”
When child labor laws were proposed to ban 7-year-olds from working in factories, corporate bully-worshipers like Mnemosyne objected, explaining, “Rome wasn’t built in a day! We have to recognize that this will take time.”
Fifth columnist corporate toadies like Mnemosyne have always been with us, like cockroaches and bad weather — these people have always worked hard to subvert progressive reform by claiming that whatever the proposal, the time is not yet. It’s always, always, always “too soon.” The proposal is always, always, always “too radical” and “not practical.” We are always told that we must wait more endless years, decades, centuries, millenia for the most basic of progressive policies because “it’s going to take time.”
Bullshit.
Either America’s broken medical system dies, or the American people do. Choose.
Either the AMA dies, or your child dies screaming like an animal from a preventable illness.
Which do you prefer?
Skippy-san
Richard, I wish you would take on the myth that seems to be spreading in conservative circles that “people are losing their insurance”. The meme goes like this: ” The stories are rolling in….people getting notifications that their current insurance policy is terminated Jan1 and their new policy will cost a little more than double” “So I got a letter from Bluecross Blueshield, my health insurance provider, on Saturday. It explained
that my current plan, the plan I chose to fit my individual needs, does not comply with Obamacare and thus had to be cancelled. It went on to say that I shouldn’t worry because I had been automatically moved to new pla…n that does meet the new Obamacare requirements. The details of my new plan are just excellent. My deductible went from $1500 up to $2500, that’s 66%. My limit on annual out of pocket expenses went up from $1500 to $6350, up 323%. I’m now covered for a bunch of things I don’t want or need, like mental illness inpatient and substance abuse inpatient treatment coverage. Now a rational person might assume that when something I chose to buy, and wanted to keep was taken from me, it would at least cost less to pay for the thing that was forced onto me. Well that’s the best part! My monthly premium went up from $139.50 to $229.19, an increase of 65%! I get to pay MORE for something I don’t even want.
I suspect that some people will see higher premiums-but that was made clear when the law was debated. It is true that for some people they have gone up-but its because they were under insured to begin with. Saying that you don’t “need” preventative coverage or mental health coverage is like saying I don’t need brakes on my car. Its true up to a point-until you need them. Plus if anyone had been paying attention-they never said that some people would not pay more. That’s because they had been getting a free ride up to that point-they just didn’t know it.
What I would like is some ammunition to respond to these folks.
jayackroyd
@Richard Mayhew: You ask a rhetorical counterfactual, so I say sure. I say the main reason a clean single payer bill wasn’t offered for vote is that a vote against it would have cost Democrats their seats. I say the main reason a clean vote with a 60 vote majority wasn’t offered was to provide cover for corrupt Democratic senators who did not want to cast that vote. I say that a clean majority vote with the president’s committed support, support based on denouncing the insurance companies that everybody hates would not only have forced such a bill through, but would have led to at least a Democratic hold in 2010.
I say further that the President was ideologically committed to a “market based” solution as well as committed to a “bi partisan” solution, that his political strategy is shaving off the sensible moderate republicans by pursuing centrist policies designed to provide a bulwark to powerful private interests.
Leaving counterfactuals aside, I do want to note that making policy concessions to the Republicans has not led to the support that Bob Dole and Tom Daschle promised us. If we’re gonna have insanity take over our political process, it’d be a lot more satisfying if it were over something that is actually good public policy.
Mnemosyne
@Skippy-san:
I’m afraid I don’t have much ammunition for you, other than asking them, “Did you bother to check the exchanges to see if you can get a better deal from a different company? Why not?”
It does kind of validate something I was guessing about this story from Malkin and other conservatives, though — they think they managed to negotiate themselves a special “deal” and they’re pissy because now people won’t need their Super Seekrit Negotiamation Skills to get a deal that’s even better than the one they had.
And if Malkin thinks she doesn’t mean mental illness or substance abuse coverage, well, I can guarantee that her poor children are going to need it sooner or later.
adhocheretic
@jayackroyd:
How do you get Lieberman to be one of the 60 for single payer?
jl
@Richard Mayhew: Contiunity of care is a big problem, and as far as I know from the numbers, a major sourse or preventable medical errors (another categroy in which US medicine is one of the world leaders). Medicaid churn is a BIG.I was unclear on the reasons. One I had heard was giving ability of enrollees to switch providers very quickly to protect lower income prople from being stuck with provider who gave bad service. I was not aware of the the extent of the problem with frequent too frequent tests wrt to changes in income. Does that change state by state?
Mnemosyne
@Skippy-san:
Also, too, people get pissy when they realize they were getting ripped off and other people are laughing at them for it, which tends to make them double down on I was not getting ripped off, was not was not was NOT! So I’m not sure there’s a lot of ammunition that will convince them otherwise.
WereBear
@Skippy-san: In my experience, people who get a “great deal” on their health insurance are people who haven’t really used their health insurance.
jayackroyd
@adhocheretic: Clean vote, simple majority I said. If you insist that there was no alternative to allowing the PPACA to be filibustered (which is ridiculous), then take Lieberman’s gavel if he won’t vote for cloture. He can still vote against the bill. That’s how party discipline used to work.