Obamacare Reform Is Looking Doubtful This Year

If you’re wondering whatever happened to the Republican health care reform bill, you are not alone. When we last heard from the American Health Care Act, House Republican leaders were waiting on the Congressional Budget Office to score the bill before submitting the legislation passed in the House to the Senate. The CBO scored the bill in late May, but the silence from the Republican ranks has been deafening. The congressional website does not show any action on the bill since it passed the House on May 4.

Readers of The Resurgent are aware that the Republican health care bill falls short of full repeal. Senate rules require 60 votes for cloture on a repeal bill and Republicans would not be able to find eight Democrats to join them in ending a Democrat filibuster. Even if Republicans eliminated the filibuster entirely, they would not have enough votes for full repeal because at least four Republicans have pledged to oppose a repeal bill that does not provide for a phase out of the Obamacare Medicaid expansion.

Now some Republicans are saying that it is doubtful that they will be able to pass even an incomplete health care reform bill. “I don’t see a comprehensive health care plan this year,” Senator Richard Burr (R-N.C.) said in Politico. “It’s unlikely that we will get a health care deal, which means that most of my time has been spent trying to figure out solutions to Iowa losing all of its insurers.” Burr serves on the Senate Heath, Education, Labor and Pensions Committee.

In the Wisconsin State Journal, Senator Ron Johnson (R-Wisc.) agreed that the first priority to would probably be to act to preserve the health insurance markets in their current form. Johnson said that a short-term “market stabilization” bill could be passed that would fund the Obamacare exchanges with billions of dollars to help prevent insurers from exiting the marketplaces. Such an approach would reduce volatility in the Obamacare markets and buy time for Republicans to agree on a reform bill.

“To me, this may be a two-part process. I would admit that’s probably a minority view in the Republican Senate right now,” Johnson said.

Senator Jeff Flake (R-Ariz.) also tried to tamp down expectations. “There are some still saying that we’ll vote before the August break,” he told the Washington Post. “I have a hard time believing that.”

The fundamental problem is that conservative and moderate Republicans do not agree how to handle various aspects of the health care issue. Although Republicans have been united in their desire to repeal and replace Obamacare since the day it was passed, they disagree on the details of what should come next.

In the eight years since Obamacare became law, Republicans such as Tom Price, formerly a Georgia congressman and now Secretary of Health and Human Services, have written legislation to repeal Obamacare and reform the health insurance industry, but the party has not coalesced around any single bill. When Donald Trump eked out a squeaker of a victory in the Electoral College, Republicans were caught flat-footed and did not have a plan for how to exploit his victory. Indications were that, as late as early February, Republicans had not even started writing an Obamacare reform bill. The Senate considers the House bill dead on arrival and is writing its own version of health care reform, which may be available as early as this week.

President Trump’s antics are also hurting the possibility of passing a health care bill. The investigation into the Trump campaign’s possible connections with Russia and the firing of FBI Director James Comey are distractions that make it even more difficult to find a compromise that is acceptable to all GOP factions. The president showed leadership in the fight to pass the AHCA in the House, but has largely been missing-in-action on the issue in the month since the House vote.

Not all Republicans are pessimistic on health care. Senator John Cornyn (R-Texas) was quoted in The Hill as saying, “We do need to take care of our business, and I think you mentioned healthcare, and that’s certainly front and center in the United States Senate — something we’re going to have to get resolved here in the next few weeks.” Cornyn said that he thought a Senate bill would be “done by the end of July at the latest.”

Repeal of Obamacare has been the centerpiece of the Republican platform since 2010. The fact that repeal is not possible, even with Republican majorities in Congress and a Republican president, is not going to please most Republican voters. If the new Republican administration leaves Obamacare completely intact, it may well face a mutiny from the grass roots.

House May Have to Vote on Health Care Bill Again

If you are wondering why the Senate hasn’t started working on the American Health Care Act two weeks after the House passed the bill, you aren’t alone. Bloomberg reports that the measure is stalled with the House leadership after being approved by a four-vote margin earlier this month.

According to Bloomberg, the holdup is a series of last minute amendments that were made before the vote in order to garner more support. The late changes have not been scored by the Congressional Budget Office and Republican leaders are waiting for the CBO numbers before sending the bill to the Senate.

If the CBO numbers don’t show at least $2 billion reduction in the deficit, it would doom the bill in the Senate because it would not qualify for the budget reconciliation process that avoids a Democrat filibuster. The GOP would be forced to start the process again with a new budget resolution in the House. Before the changes, the bill was projected to save about $150 billion over 10 years.

“We’ve got to wait for the CBO score to prove that you meet the reconciliation test,” said Rep. Greg Walden (R-Oreg.), chairman of the House Energy and Commerce Committee.

A Republican aide told Business Insider that Republicans expected positive results from the CBO, but were waiting for the report to be sure. “Based on the previous two scores, we believe we’ll hit our target deficit reduction number but we’re holding out of an abundance of caution,” the aide said.

If the House has to vote on the bill again, passage would not be a slam dunk. In the first vote, 20 Republicans joined every House Democrat in voting against the bill. The current version of the bill was specifically crafted to gain enough support from disparate Republican factions to pass. If the bill has to be changed to satisfy budget reconciliation requirements, the fragile balancing act may be upset and changes may cost too many Republican votes to pass the bill a second time.

The CBO report is expected next week.

New Cruz? Texas Senator Works For Health Care Compromise

Texas Senator Ted Cruz has developed a reputation as a firebrand. Cruz has made refusal to compromise a trademark of his career in Congress and has often had strong words for fellow Republicans who disagreed with him on strategy. Now a new behind-the-scenes report by the Wall Street Journal reports that Cruz may be turning over a new leaf.

The Journal reports that Cruz began working quietly with moderate Republicans to find a consensus on health care reform that has a realistic chance of becoming law. Cruz was instrumental in forming a working group of 13 Senators that had its origin in a February steak dinner with Sen. Lamar Alexander (R-Tenn.). The group includes Republicans concerned about the effect of an outright repeal of Obamacare’s Medicaid expansion and pre-existing conditions rules such as Rob Portman (R-Ohio), Tom Cotton (R-Ark.), Cory Gardner (R-Col.) and Mike Lee (R-Utah). Cruz has reportedly been working with House Freedom Caucus Chairman Mike Meadows (R-N.C.) for the past month.

Senators on both sides of the aisle expressed surprise at Cruz’s new strategy. “It’s a ‘you live long enough, anything can happen’ moment,” said Lindsey Graham (R-S.C.).

“It would be a first for Sen. Cruz,” noted Chris Murphy (D-Conn.).

The GOP’s 52-vote majority in the Senate means that Republicans can lose no more than two votes and still be able to pass an Obamacare replacement. A defection of two Republicans would require Vice President Mike Pence to cast the tie-breaking vote. At least five Republican moderates are considered to be doubtful in their support for the American Health Care Act.

The working group is expected to be vital in bringing various Republican factions in the Senate together to forge a compromise that can replace as much of Obamacare as possible. Cruz’s participation and support may help bring other conservatives such as Mike Lee and Rand Paul (R-Ky.) on board with the Republican reform effort.

In the past, Cruz has had difficulty with consensus building and passing legislation. He is perhaps most well-known for his role in the 2013 government shutdown and attempt to defund Obamacare. With Republicans outnumbered by Democrats, the shutdown failed to halt the implementation of President Obama’s namesake health bill. Cruz was also known for failed attempts to prevent an increase in the debt ceiling and compromise spending bills under the Obama Administration.

Cruz may be realizing that the role of majority party senator is very different from that of one who serves in the opposition. When a party is in power, it is expected to deliver results in the form of advancing its legislative agenda. It is not enough to just say “no” when your party controls both houses of Congress and the White House.

“They’re giving him a leadership role and he’s going to have to make the most of if it,” said Rick Tyler, who served with Cruz’s presidential campaign. “If he can pull it off it’s a huge victory. But it’s fraught with danger.”

The upside for Cruz would be an enormous amount of prestige and notoriety if he shows an ability to build a coalition to pass a landmark reform bill. The boost for Cruz could potentially reach beyond his normal conservative base and lay the groundwork for a second presidential campaign in 2020.

Without the support of Cruz and other Senate conservatives, a reform effort would necessarily have to reach across the aisle to Senate Democrats. That would mean fewer conservative reforms in a watered-down bill. The alternative would be to delay reform until after the 2018 elections or until health insurance markets become so dysfunctional that the public demands action.

A potential pitfall would be alienating the conservative base whose expectations are for a full repeal of Obamacare. Even though Republicans do not have the votes for a full repeal, Mr. Cruz has helped stoke those expectations over the past few years. Many conservatives view anything short of full repeal to be a betrayal. Cruz must help the party overcome that view and sell the reform bill to the conservative base.

Health care reform gives Ted Cruz an opportunity to break out of his stereotypical role as a roadblock in the Senate. If Cruz can prove that he has the ability reach out and build a working majority with senators who don’t share his views, it would represent a major milestone in his career make him an even greater force in the Senate.


AHCA May Be Best Chance to Replace Obamacare In Our Lifetime

The House of Representatives finally passed a bill to gut Obamacare and many conservatives are upset. Admittedly the bill is not full repeal. It is far from perfect. If I was going to write a health care reform plan, the American Health Care Act would not be it. Still, I’m very glad that the House passed the bill and I fervently hope that the Senate moves the legislation forward. Why? Because it is the only health care reform that has any chance of passing.

Many myths have grown up around Obamacare and the Republican repeal and replace effort. Over time, we have forgotten that Obamacare was not passed by a budget reconciliation. “HR 3590, the Patient Protection and Affordable Care Act,” was passed on Christmas Eve 2009 after a cloture vote by 60 Democrats ended a Republican filibuster. It was a traditional bill that requires a traditional bill to repeal.

So, what was the controversy about the budget reconciliation? After Scott Brown (R-Mass.) was elected to the Senate, the Democrats could no longer break Republican filibusters. If the Democrat-controlled House amended the ACA, it would be subject to another cloture vote, which the Democrats would lose. The answer was to have the House pass the bill unchanged and use the budget reconciliation process to pass a second bill, “HR 4872, The Healthcare and Education Reconciliation Act,” by a simple majority vote. This bill was subject to the same limitations that the GOP now faces in passing their own budget reconciliation.

Even though Republicans hold the presidency and control both houses of Congress, they were not granted a blank check by voters. A full repeal would require 60 votes for cloture in the Senate and there are only 52 Republicans. The mathematical problem is obvious.

But what about the 2015 repeal bill that was vetoed by President Obama, you may ask. Republicans didn’t have 60 votes in 2015 either, but they passed a repeal bill then. Why can’t they do it now?

The answer is that the 2015 repeal bill was not a full repeal either. The 2015 bill, was also a reconciliation bill that carried the unwieldy title, “HR 3762 To Provide for Reconciliation Pursuant to Section 2002 of the Concurrent Resolution on the Budget for Fiscal Year 2016.” The text of the bill states in Section 102 that the ACA “is amended,” not repealed.

If the 2015 bill was better that the AHCA of 2017, it is for two reasons. First, there were 54 Republicans in the 114th Congress where there are only 52 now. The GOP could afford to lose more votes in the Senate in 2015 that it can today.

Second, four Republican senators who voted for the 2015 bill now say that they won’t vote for a bill that does not provide for a phase out of the Medicaid expansion. Sens. Rob Portman (Ohio,) Shelley Moore Capito (W.Va.), Cory Gardner (Colo.) and Lisa Murkowski (Alaska) refuse to back the same bill that they voted for two years ago. Sen. Susan Collins (R-Maine) voted against the 2015 bill and would presumably do so again. Other Republicans are reluctant to repeal the popular provision concerning pre-existing conditions. It is these five senators and House moderates, not the Republican leadership or President Trump that are forcing a more watered-down version of the bill.

Some conservatives suggest that Republicans should get rid of the filibuster to pass a repeal. We wouldn’t need 60 votes then and the Democrats will probably kill it anyway the next time they have a majority, they argue.

The problem with this strategy is that full repeal could not even win a simple majority vote. The five Republican defectors in the Congress and the Tuesday Group of 50 Republican moderates in the House would kill it.

Removing the filibuster would also mean that Democrats would only need simple majorities to replace Republican health care reform with a national single-payer system the next time they control both houses of Congress and the presidency. It would also usher in a host of other bad ideas from gun control to a higher minimum wage to higher taxes to onerous regulations on practically everything. It is true that Democrats might one day choose to remove the filibuster, but it is certain that if Republicans remove it now, for no strategic reason, Democrats will have a field day when they return to power.

What, then, are the options for Republicans on Obamacare? One option is to wait and hope for a filibuster-proof majority. If you favor this option, be aware that the last time that Republicans had a 60-vote majority was the 61st Congress from 1909 to 1911. It is extremely likely that before the Republicans get a supermajority, Obamacare will implode, health insurance premiums will skyrocket, insurance companies will cancel policies and hell will freeze over. I have little doubt that if Republicans hold out for the perfect, full repeal bill that I will die of old age with Obamacare still intact. (I’m only 45.)

Waiting until 2018 might give the Republicans a few more votes to craft a better compromise. It is also possible that two years into the Trump Administration, voters might deliver a rebuke to Republicans in the form of Democrat majority in either the House or Senate that makes any sort of conservative impossible. In any event, it is doubtful that the numbers would change enough in the GOP’s favor to justify putting off a cornerstone promise of the campaign for two years. The longer Republicans wait to take action, the more entrenched Obamacare will become.

A better option is to take baby steps toward the full repeal of Obamacare starting now with the AHCA. The current bill has the support of moderates as well as the Freedom Caucus and has decent chance of becoming law. While far from ideal, it is a reasonable bill that can hopefully be improved further in its journey through the Senate. Even if it became law in its current form it would mark a vast improvement over Obamacare.

The Republican reform bill should not be viewed as a final step, but as a first step toward total repeal. Without a supermajority, it may take years of nibbling at the edges of Obamacare to fully repeal the behemoth, but conservatives have to start somewhere. The logical place to start is the bill that has the support of the two disparate factions of the GOP. The only bill that has a chance of becoming law.

Conservatives must decide whether it is worth trading a chance to gut Obamacare now to wait for a perfect bill in the distant future. The answer should be obvious. We should not allow the perfect to be the enemy of good and the possible.

Seize the day and start saving American healthcare!




Red State Republican Deserts GOP On Obamacare

In a surprise announcement that underscores the difficulty that Republicans are having in assembling a majority to replace Obamacare, a Republican congressman from the red state of Missouri has announced that he will not support the current health care reform bill. After supporting earlier versions, Rep. Billy Long (R-Mo.) has become the latest conservative to jump ship and oppose the Republican effort to scuttle Obamacare.

Long represents Missouri’s seventh congressional district, a deep red district in the southwest corner of the state that includes Branson and Springfield. The district has been represented by a Republican since 1961. Voters there supported Donald Trump by a 70-25 percent margin over Hillary Clinton. Trump’s margin there was larger than that of any Republican presidential candidate this century. Long won both the 2016 primary and general election with more than 60 percent of the vote.

The conservative nature of Long’s district makes it all the more surprising that he would not be on board the Obamacare replacement effort. According to a statement by Long in Politico, it came down to how the Republican bill dealt with pre-existing conditions.

“I have always stated that one of the few good things about Obamacare is that people with pre-existing conditions would be covered,” Long said. “The MacArthur amendment strips away any guarantee that pre-existing conditions would be covered and affordable.”

The MacArthur amendment is a compromise reached between Rep. Tom MacArthur (R-N.J.) and Freedom Caucus Chairman Mark Meadows (R-N.C.). The amendment would allow states to seek waivers for several provisions of Obamacare such as benefits that are required to be covered under the law and the ban on allowing companies to charge more based on a person’s health history.

MacArthur told CNN that the plan would protect people with pre-existing conditions while giving states more flexibility. “We need to protect the most vulnerable people in the current plan. These are people with pre-existing conditions,” he said. “We want to make sure they are protected. Secondly, we have to give the states flexibility to bring premiums down for everyone else.”

Long’s opposition to the amendment underscores the difficulty that Republican leaders have in finding a balance between moderate and conservative viewpoints on healthcare. Like Long, even many Republican voters who have favor repeal of Obamacare find parts of the law attractive.

One of the most popular aspects of the health law is the provision that requires insurance companies to cover people with pre-existing conditions. A CNN/ORC poll from March found that 87 percent of voters favor “maintaining the protections offered to people with pre-existing conditions under Obamacare.” The numbers are unchanged across the political spectrum with 87 percent of Republicans and 85 percent of conservatives agreeing with the statement.

Such overwhelming opposition explains why so many Republican congressmen are reluctant to get on board with conservative plans to eliminate the requirement to cover pre-existing conditions. With a lifetime American Conservative Union rating of 91 percent, Long is no moderate or squish. A member of the House of Representatives since 2011, Long has undoubtedly learned to listen to constituents and is most likely hearing from many of them that they want pre-existing conditions covered.

The economic difficulty is that there is no free lunch. If pre-existing conditions are covered, many people won’t buy health insurance until they get sick. If people only buy insurance when they are sick, the cost of coverage goes up.

The Republican difficulty is that the free market position held by many conservatives is that the government should not mandate that insurance companies cover pre-existing conditions. This conflicts with the popular opinion of voters that people with pre-existing conditions should not be denied health insurance. The conflict has caused a schism in the party between those, often from safe Republican districts, who favor free market policies and those who are listening to the majority of voters.

There is also a time factor. Republicans lack the 60-vote majority in the Senate to avoid a filibuster so they are relying on the budget reconciliation process to pass their health care reform. If they cannot get agreement on health care, the budget reconciliation opportunity will vanish for another year.

The conundrum is similar to the one that Democrats faced in 2010 when they passed the Affordable Care Act. Poll after poll showed that voters opposed the Democrat version of health care reform. A CNN/Opinion Research poll taken just before the bill’s passage found that 59 percent opposed Obamacare. Democrats forged ahead against public opinion and paid for their arrogance with the loss of the House, the Senate and ultimately the White House.

The lesson is one that Republicans should take to heart. An election victory is not a blank check from the voters. If Republicans force an unpopular policy on the country, they may well find themselves punished by voters in 2018 and beyond. The defection of conservatives like Billy Long may be a bellwether of a rising public anger that could endanger the Republican majority.

Still a Crap Sandwich, But With Flavor!

Conservatives have prevailed, it would seem, and convinced both the White House and House leaders to go along with amendments that would move Obamacare closer to repeal. But let’s cut the crap and the spin — this is not repeal, it does not deliver on long held promises, but this appears to be the best that they can do.

Liberal Republicans, like Charlie Dent, who played up voting for the 2015 repeal effort and voting to override President Obama’s veto, now pretends he never did that. He and a large number of other Republicans want to keep Obamacare in place.

The House Freedom Caucus, despite the barbs, jeers, and attacks from the Wall Street Journal editorial page to a host of establishment oriented pundits to the President himself, held their ground and demanded the legislation move right. They should be commended.

They’re going to vote for this now. I still think they should just leave it all alone. The moment they vote for this plan, which will not repeal Obamacare or really even fix it, they are going to own every bit of it. The media and Democrats will attack them for every pre-existing flaw in Obamacare that is not going to get fixed by this legislation.

But the GOP has convinced itself to self-immolate and far be it for me to try to throw water on the match. They will set themselves on fire and probably get wiped out next year. But they’ll look themselves in the mirror and convince themselves they did their best to slay the Obamacare dragon. When the base does not show up for them next year, this will be the reason. But they’ll excuse it all away as they have every defeat since 2006. Conservatives will no doubt get the blame again.

The House Freedom Caucus should be commended. Mark Meadows, Jim Jordan, and the rest held their ground, often with their home state colleagues attacking them in local press back home. But they did not budge. They demanded improvements in the legislation. They demanded a shift to the right in the legislation. And they got it. They improved the bill.

Let’s just not pretend this is no longer a crap sandwich. It still is. But the flavor is improved. No side ever gets everything they want. Conservatives are not going to get repeal. But liberals will have to accept state experimentation instead of a one size fits all national healthcare structure.

Consider this a “win” because it isn’t going to get any better than this.

NEW: Trump Threatened to Primary Representative if He Voted Against American Health Care Act (AHCA)

Representative Mark Sanford (R-SC) went on CNN’s State of the Union program and confirmed earlier reports of President Trump’s threat to primary representatives if they did not vote for Trump’s replacement to the Affordable Care Act:

“He [Trump] sent as his emissary Mick Mulvaney, who I’ve known for a long time – he’s from our state, and he’s now the OMB director – he said: ‘The president hopes you vote against this because he wants to run somebody against you if you do…”

Representative Sanford went on and explained to the host, Dana Bash, why he wasn’t afraid of Trump’s threat to primary him:

 “Well no, it’s not that. It doesn’t make anybody’s day when the President of the United States says: ‘I wanna take you out.’ But what I would say is I don’t work for him, I work for about 750,000 people here in the first congressional district.

I’ve had eight town hall meetings – I finished my eighth one just this week – over the last couple of months, and what I’ve heard from people at a level that I’ve never before heard in the world of politics is that people care deeply about this issue, it impacts them directly and very personally, and we better get it right. And the idea of checking the box saying: ‘We dealt with healthcare,’ but not taking into account both considerations to the left and the right on this one, I think, ultimately – not my job.

My job is to watch out for the folks that I’m hearing from here at home, and to induce conservative ideals that I ran on, and I’m trying to do just that.”

Mark Sanford is right. The job of a Representative is to do the job that the people elected him to do; not to be the President’s yes man.

This new report should come as no surprise because of who Trump is but it does raise some questions about Trump because in the end, ACHA was defeated. Is Trump really a good negotiator? Does he still have some power left to keep Republicans from outright defying him? And lastly and more importantly, will Trump follow through on his threat to primary those that did defied him?

Red States Consider Medicaid Expansion After Health Bill Fail

The failure of the American Health Care Act may have an unintended consequence that will make it harder to dislodge Obamacare’s entitlements in the future. After Speaker Paul Ryan’s admission that “We’re going to be living with Obamacare for the foreseeable future,” several red states are considering Medicaid expansions under the Affordable Care Act.

The Wall Street Journal reports that 19 states, most of which are reliably Republican, rejected the ACA’s Medicaid expansion to cover low-income families after the Supreme Court struck down the mandatory expansion of Medicaid and made it optional for the states. Federal funding for the expanded program was covered at 100 percent for three years and would reduce to 90 percent in 2020. The federal government typically pays about 60 percent of Medicaid spending.

“The thing that held states back was that they were going to end Medicaid expansion,” Adam Searing, a research professor at Georgetown University’s Center for Children and Families, told the Journal. “Now when you have the House speaker saying this is going to stay, it’s like, ‘We may get the money, why not explore it?”

The Kansas Senate voted to approve the Medicaid expansion on Tuesday, two working days after the Republican health bill failed. CNN reports that the Kansas House had passed the bill earlier this year. The bill now goes to Gov. Sam Brownback (R) who is not expected to sign it into law.

“To expand Obamacare, when the program is in a death spiral, is not responsible policy,” Gov. Brownback said.

The Journal reports that several other states are expected to reconsider the Medicaid expansion since the ACA now appears to have survived the Republican challenge. These include Idaho, Florida, Georgia, Missouri, Utah and Wyoming.

North Carolina’s Democrat governor, Roy Cooper, initiated the Medicaid expansion process after taking office in January. The Winston-Salem Journal said that the expansion was a top priority for Gov. Cooper, but he has met resistance from Republicans in the General Assembly.

Ironically, a Republican administration may make it more likely that red states buy into the Medicaid expansion. Secretary of Health and Human Services Tom Price has the power to issue regulations that affect how Medicaid money is spent. A more conservative approach that includes work requirements and more leeway on how states spend Medicaid money may entice Republican state governments to opt in.

If more states enact the expanded Medicaid entitlement, it will be even harder to kill Obamacare in the future. The AHCA was derailed by Freedom Caucus members who, among other things, objected to the way the bill handled the expansion. The AHCA’s slow phase out of the Medicaid expansion was made necessary by four Republican Senators (Lisa Murkowski of Alaska, Corey Gardner of Colorado, Rob Portman of Ohio and Shelly Moore Capito of West Virginia) whose states elected to buy into Obamacare’s Medicaid expansion. If more states expand Medicaid, it is likely that more Republican congressmen will decide to protect the federal Medicaid money flowing to their states.

Some popular Republican governors are already resisting the repeal of the Medicaid expansion as well. John Kasich (R-Ohio), who finished third in the 2016 Republican primary, called the Republican plan to repeal the expansion “a very, very bad idea” according to CNN.

The Trump Administration denies that the effort to repeal Obamacare is over, but there seem to be no plans to move forward. “Have we had some discussions and listened to ideas? Yes,” Press Secretary Sean Spicer told the Journal. “Are we actively planning an immediate strategy? Not at this time.”

As more states and taxpayers receive federal Obamacare money, the law will be harder and harder to repeal. Government money has the power to make addicts of both individuals and states.