Hospitals Brace for Nightmare of Obamacare Repeal

Back before many Trump voters cast their votes in what amounted to a possible act of suicide, I noted that many rural hospitals in Southwest Virginia - and a few urban hospitals too - faced possible bankruptcy and closure should Obamacare (as the new Gilded Age advocates in the GOP call the Affordable Health Care Act) be repealed.  Now, once Trump is sworn in and the GOP controls both houses of Congress, what hospital systems feared may be about to happen.  The irony is not only will many of the GOP voting areas see large numbers of residents losing health care coverage, but their local hospitals - typically among the locale's largest employers - closing down. It's as if these regions decided to not only take a fatal drug overdose, but also put a bullet in their own heads simply to satiate their hated of others with different skin colors, religious faiths and/or sexual orientation.   In my view, these voters deserve whatever horrors may befall them.  A piece in the New York Times looks at the self-inflicted threats to hospitals serving these cretins.  Here are excerpts:

PHILADELPHIA — Jason Colston Sr. went to the emergency room at Temple University Hospital last month with his calf swollen to twice its normal size. A bacterial infection had entered his bloodstream, requiring him to spend nine days at Temple, where patients are overwhelmingly poor.

Mr. Colston, 36, had no insurance through his job at a 7-Eleven, but it turned out he was eligible for Medicaid under the Affordable Care Act. Temple helped him enroll as soon as he was admitted, and Medicaid paid for his stay and continuing treatment.

Before the health law, the hospital had to absorb the cost of caring for many uninsured patients like Mr. Colston. Now, with President-elect Donald J. Trump and the Republican-controlled Congress vowing to dismantle the law, Temple and other hospitals serving the poor are bracing for harsh financial consequences that could have a serious effect on the care they provide.

Since the election, hospitals have been among the loudest voices against wholesale repeal of the health law. In a letter to Mr. Trump and congressional leaders this month, the two biggest hospital trade groups warned of “an unprecedented public health crisis” and said hospitals stood to lose $165 billion through 2026 if more than 20 million people lose the insurance they gained under the law. They predicted widespread layoffs, cuts in outpatient care and services for the mentally ill, and even hospital closings.

The stakes are particularly high for safety-net hospitals like Temple, but even more prosperous hospitals face uncertainty after investing in new ways to deliver care under the law.

Temple executives estimate their system could lose as much as $45 million a year if the law were entirely repealed, which would return it to the losses it posted for years before the health law took effect.

“We are the de facto community hospital in one of the poorest neighborhoods in the country,” said Robert Lux, the senior vice president, treasurer and chief financial officer of Temple University Health System, which includes two general hospitals and a cancer center. “Any kind of change like this would not only push Temple University Hospital into financial extremis, it would do the same thing for our entire system.”

Still, even hospitals serving affluent populations have reason to be nervous about a future without the health law. Main Line has invested substantially in response to the law’s push to base hospital pay on patient outcomes instead of the amount of medical services provided. Repealing the law would create uncertainty about the future of this new paradigm, which has forced hospitals to rethink how they deliver care.

Over all, the health law has improved the financial outlook of Pennsylvania hospitals significantly, even though the state was a year late in expanding Medicaid. The former governor, Tom Corbett, a Republican, initially balked, and the program did not expand here until 2015. Still, hospital operating margins statewide increased to about 5.5 percent on average in 2015, from 4.25 percent in 2014, according to the Hospital and Healthsystem Association of Pennsylvania. The amount of care provided to patients who cannot pay dropped by 8.6 percent on average.

Under the health law, hospitals that served a large number of poor and uninsured patients agreed to a series of funding cuts in exchange for getting far more patients with insurance coverage. Temple has lost about $11 million so far in these federal funds, known as disproportionate share payments, Mr. Lux said.

But like other hospitals in the 31 states that expanded Medicaid under the law, it has made up that revenue in part through the Medicaid expansion. It recorded about 13,000 more visits from patients with Medicaid coverage in 2015, the first year Pennsylvania expanded Medicaid eligibility, and at least as many this year. Still, Temple is barely turning a profit: It had operating income of $3.6 million in the fiscal year that ended June 30, despite revenue of $1.7 billion.  “Our current state of stability could be broken pretty quickly.”

So, too, could Temple’s efforts to connect its newly insured patients with preventive care instead of waiting until they show up in the emergency room with advanced, expensive illnesses. Dr. Robert McNamara, chairman of emergency medicine at the Lewis Katz School of Medicine at Temple University, said he had seen more than a few uninsured people arrive in the emergency room with kidney failure, needing costly dialysis for the rest of their lives because they had lived with high blood pressure for so long.

“We were finally in a situation where for most of our patients there was a coverage option,” said Anita Colon, Temple’s director of patient financial services, already speaking about the health law in the past tense. “Now there’s just a total unknown about what will be left.”

What is most troubling is that human excrement like Paul Ryan and many of the 81% of evangelicals who voted for Trump simply do not care about what happens to others.  They go to church each week and act all pious, yet in reality they are worse than the Pharisees of the Bible.  Their version of Christianity is a foul evil.  

Trump and His Supporters Push "Racial Amnesia"

Many in the media and pundit circles - even some shortsighted Democrats - are spreading the meme that Donald Trump's election win was the result of a revolt by white working-class voters.  According to this deliberate myth, racism, sexism and religious bigotry had little, if anything, to do with it.  It was all about economics and a need for hope and/or desire for "change." As a piece at CNN points out, this myth has about as much credence as the South's myth of "The Lost Cause" which would have one believe that the Civil War was all about states' rights, that defending slavery had nothing to do with the cause of the war, and that the antebellum South was  like the barbecue at Twelve Oaks in "Gone With the Wind."  Why the effort?  Put simply, Trump voters - and MANY were not economically stressed white working class - do not want to admit to themselves or their children and grandchildren or to have history recount that racial bigotry was a principal factor in their vote for Trump.   This myth must be challenged and dispelled immediately.  Gone With the Wind might have been a good book by some standards, but it was not remotely accurate history. Neither is the story line that white racism didn't propel trump to the presidency. Here are article highlights:

After President-elect Donald Trump's recent victory, some of his supporters celebrated by flying Confederate battle flags from pickup trucks and waving them at rallies.

But Trump's victory may mark the resurgence of the Old South in another more sinister way: The return of "racial amnesia."

That's what some historians are saying as they watch a familiar storyline emerge. Trump's triumph is now being roundly described as a revolt by white working-class voters; racism, sexism and religious bigotry had little, if anything, to do with it.

People making this argument are following a script first honed by another group of Americans who made history disappear. After the Civil War, "Lost Cause" propagandists from the Confederacy argued the war wasn't fought over slavery -- it was a constitutional clash over state's rights, they said; hatred toward blacks had nothing to do with it.

It was an audacious historical cover-up -- to convince millions of Americans that what they'd just seen and heard hadn't really happened. It worked then, and some historians say it could work again with Trump.

"It's already happening again," says Brooks D. Simpson, a leading Civil War historian who teaches at Arizona State University. "A lot of people are saying we're going to have to unite behind the new guy and forget what he had to say. People who feel that they are part of those populations targeted by Trump are going to be told by whites to get over it."

At first glance, comparing some Trump supporters to ex-Confederates may seem absurd, even insulting. But historians say both groups developed an uncanny ability to obscure the role race played in transformative events and to persuade millions of Americans to go along with the charade.

You don't have to pick on the South, though, to spot racial amnesia. Racism is embedded in the daily lives of ordinary Americans in ways that many forget.

Where Americans live, worship, send their children to school -- much of it is driven by race, says David Billings, a pastor who came of age as a white Southerner during the 1960s.

After the civil rights movement sparked the passage of laws that banned overt racism in the 1960s, many whites "built another country" in defiance of government dictates, Billings wrote in his new memoir, "Deep Denial: The Persistence of White Supremacy in United States History and Life."

"Across the country, white people withdrew from the 'public' sphere and migrated to 'whites only' suburbs to evade racial integration. ... The word 'public' preceding words like 'housing,' 'hospital,' 'health care,' 'transportation,' 'defender,' 'schools,' and even 'swimming pool' in some parts of the country became code words that meant poor and most often black and Latino. The word 'private' began to mean 'better.' ''

Consider a contemporary issue that seems race-neutral -- the movement to give vouchers to public school students for private school. That effort started in the 1950s because many white Americans didn't want their children to attend newly integrated public schools, says Kevin M. Kruse, author of "White Flight: Atlanta and the Making of Modern Conservatism." Most Americans have forgotten that today, Kruse says.

"There's a real reluctance of some to acknowledge the part that race has played in American history," he says. "You cannot understand American history without understanding the fault lines of race. If we turn a blind eye to it, we're going to miss an incredible amount of the picture."

The Lost Cause campaign offers the definitive example of racial self-deception. Before there was fake news, the Lost Cause propagandists were creating fake history.

Their timing was audacious. They didn't wait years to claim the Civil War wasn't fought over slavery. They started making those claims immediately after the war ended, when the physical and psychological wounds were still raw.

A year after the war ended, Edward Pollard, a Southern newspaper editor, published, "The Lost Cause: A New Southern History of the War of the Confederates." Former Confederate leaders began to amplify Pollard's argument that the war was over state sovereignty, not slavery. Jefferson Davis, the former president of the Confederacy, claimed that "slavery was in no way the cause of the conflict." Alexander H. Stephens, the former vice president of the Confederacy, argued the war "was not a contest between the advocates or opponents of that peculiar institution."

Confederate veterans' groups started to spread the myth at reunions. So did storytellers. The Lost Cause was recycled in early 20th century films like D.W. Griffith's "Birth of a Nation," "Gone with the Wind" and Walt Disney's "Song of the South." All recast the antebellum South as a moonlight and magnolia paradise of happy slaves, affectionate slave owners and villainous Yankees.

Why would so many Southerners embrace such a big lie?  Part of it was embarrassment. They had to decontaminate history by recasting what they did as a noble cause, historians say.

They also wanted to look good to their children and future generations, Civil War historian Alan T. Nolan wrote in "The Myth of the Lost Cause and Civil War History."
"The Lost Cause was expressly a rationalization, a cover-up," Nolan said.

The Lost Cause myth took hold even though Americans could easily consult the public record. The declarations of secession made by Southern states on the eve of the war cited slavery as the cause. And Stephens, the Confederate vice president, said in a speech in South Carolina in 1861 that the Confederacy was not founded on the "false idea" that all men are created equal.

"The Confederacy, by contrast, is founded upon exactly the opposite idea; its foundations are laid, its cornerstone rests, upon the great truth that the negro is not equal to the white man; that slavery, subordination to the superior race is his natural and moral condition," Stephens said.

The same dynamics that nurtured the rise of the Lost Cause are evident now, some historians say.

Those who deny that racism and xenophobia were central to Trump's victory are engaging in another Lost Cause cover-up, they say.

"Anybody who says that the recent election is not, at least in part, a racial event is functioning as an apologist, whether they know it or not, for white prejudice," says, Joseph Ellis, a Pulitzer Prize-winning historian.

There are abundant examples of Trump's explicit racist statements. He didn't campaign in dog whistles; he used a bullhorn. He once called Mexican immigrants "rapists" and proposed a travel ban on all Muslims entering the United States. Even Republican House leader Paul Ryan once said Trump's comment that a federal judge couldn't do his job because of his Mexican heritage was "the textbook definition of a racist comment."

Trump's rise to political prominence was driven in part by a conspiracy theory coated in racism. . . . . Those who say white voters can't be racist because they elected a black president twice are ignoring another inconvenient fact: Obama was elected despite opposition from white voters, political scientist Cornell Belcher told Vox in a recent interview.

He said whites didn't put Obama in the White House. Obama grabbed only 43% of the white vote in 2008 and 39% in 2012.

"The majority of whites did not elect Obama, and that's the wolf at the door," Belcher told Vox. "The vast majority of whites did not support President Obama and President Obama won back-to-back majorities, and that caused the realization of their power waning. Mitt Romney ran up a higher score among white voters than Ronald Reagan when Reagan had a landslide in 1984."

Sadly, this effort at myth making is all too consistent with the track record of Trump and the  81% of evangelical Christians who voted for him: lying and appealing to hatred towards others is their stock in trade.

Thursday Morning Male Beauty - Pt 1

Quote of the Day: Red State Stupid; Red State Mean

A number of my posts since November 8, 2016, have focused on the stupidity - no more Political correctness required according to Der Fuhrer - and meanness of Donald Trump's white working and middle class voters.  These people were only too willing to let their hatred towards others, bigotry and resentment of others lead them to vote for a man and a political party that will gleefully kick them to the curb and perhaps literally die in the case of those who lose healthcare coverage. These folks by their own actions are the definition of mean and stupid. They deserve zero respect and zero understanding.  Apparently, I am not the only person who feels this way.  A friend shared a blog post that perfectly sums up Trump voters who are now worried that Obamacare will be repealed. Here are the best quotes:  

I want to talk a little bit more about what I call, in our blissfully post-PC era, Red State Stupid. Red State Stupid is also really Red State Mean.  It’s shoot-off-your-nose-to-spite-your-face mean. And I don’t think that we can separate the two

My friend J. says that you can identify, with 100% accuracy, Democrats vs. Republicans with one simple test.  Democrats, he says, don’t care if some “undeserving” folks cash in on, for example, a free lunch program, as long as not one child goes out to recess hungry.  While Republicans, according to J., don’t really care how many children starve as long as not one, single “undeserving” child gets a free meal.

I think J. is right.  It’s pretty clear where I come down.

And I’ve been coming back to his test over and over as I ponder this article that I cited earlier about a woman whose husband will die without Obamacare but who voted for Trump in spite of Trump’s and the Republican Party’s explicitly-avowed intent to destroy the very program keeping her husband alive. . . . .

 

Just to be crystal clear, we’re talking about a woman who voted for the candidate who promised to cut off the only thing that is keeping her husband alive because she’s just that pissed at some poor elementary-school kid who got an Xmas gift.  (Be sure to tell her “Merry Christmas” and not “Happy Holidays.”  She’s sent off more money than she can afford to some Elmer Gantry who got her all hepped up on the War on Xmas.  Jebuz is the reason for the season.   . . . . .  but some poor kid getting an Xmas present is JUST TOO GODDAMN MUCH FOR HER.)  That damn kid got an Xmas gift even though his parents received a few dollars of welfare and food stamps and she’s just NOT HAVING IT anymore.

 

Here’s a six-year old who got a Tonka truck and a stocking cap at Xmas and here’s her husband getting the health care that keeps him alive.  And she’s so damn mad at that six-year old that she’s willing to risk her husband.  Fuck the love of her life.  If he dies, so be it, but at least Trump won’t be handing out hand-knit scarves and tea sets to those undeserving brats. *

The post author goes on to address something else I advocate: turning the under 27% of registered voters who voted for Trump into shunned outcasts.  Here's the quote:

So let me say this loud and clear:  That woman is evil, and venal, and stupid and she’s not going to stop voting out of hate even if Democrats nominate another white man and even if he, what . . . ?  What is it that the Democrat is supposed to do to win her vote? 

I have two things to say:  (1)  Shunning, shaming, and blaming are actually effective tactics of social control.  See, e.g., Mothers v. Drunk Driving.  And pretending that stupid people are really just simple farmers, people of the land, the common clay of the new West who would suddenly vote in their own best interests if only a Democrat would finally go hunting, or ride a motorcycle, or get in a tank hasn’t worked for the last half century or so and I’m now ready to try shaming them and focusing on how they’re not the cool kids who are in with the in crowd; (2) If we’re not going to magically convince Ms. Red State Mean to vote in her her own self interest (and we’re almost certainly not), then we’re going to have to figure out how to get other voters to the polls with the needed ID.  And that effort needs to start now.  Waiting until a few weeks before the election to get them IDs is too late.

 The shaming, however, MUST include evangelical and fundamentalist Christians, 81% of whom voted for Der Fuhrer.  They are evil and embrace stupidity and ignorance.  I left the GOP right around the time the "godly Christians" began to heavily infiltrate the GOP and the meanness and ugliness of today's GOP directly reflects the "values" of these people.  Polite society and responsible political parties need to shun these people. 

Wednesday Morning Male Beauty - Pt 2

Trump Has Released a Malevolent Spirit Upon America

I truly do not remember a year end where I have had such a sense of dread and foreboding as the new year approaches as I am now feeling.  In 23 days a dangerous demagogue with fascist leanings will be sworn in as president after which havoc will be wreaked on the federal judicial system and many other institutions and programs.  Of course, as a gay man, I have much to fear, especially if Trump keeps his promise to the Christofascists and signs the disingenuously named "First Amendment Protection Act" into  law.  A law that will give Christian extremist total freedom to ignore non-discrimination laws and ordinances if they infringe on Christofascists "religious beliefs."  As written, the law opens the door to bullying and worse.  In short, it is hard to thing of 2017 with anything other than dread.  Kathleen Parker picks up on this foreboding in a column.  Here are excerpts:

As usual, the year’s end brings reflections and ruminations on what was and what is to be. This time around, however, it feels as though an era is coming to an end.

That gentle frisson between past and future about which columnists customarily write feels vaguely apocalyptic as we approach the new year.

The usual regrets — too much ice cream, not enough exercise, too quick with a retort, not enough thank-you notes — all feel quaintly irrelevant juxtaposed against a collection of very real fears about the future. During a year of bitter political infighting — sister against sister, neighbor against neighbor — we’ve lost a better part of ourselves and unleashed armies of vengeful strangers.

To put a fine point on it, Donald Trump’s election has released a malevolent spirit upon the land. He invoked the magic message — essentially them vs. us — and the demons disembarked from their dark hiding places. He raided the lost ark and lifted the lid, and the whirlwind of humankind’s worst impulses escaped.

[W]hen the next leader of the free world casually comments that we need to build up our nuclear arsenal — and seems to welcome a return of the Cold War — alarm expressed in the strongest terms possible is required. When such alarm did find expression around the nation and the world, the president-elect huddled in his “fake news” bunker and claimed that his remarks were quoted incompletely. 

My guess is the rest of the world is thinking the exact same thing: This president-elect is not in his senses — and he makes no sense.

And, really, again. What’s with making such war-mongering threats when you’re not in the White House yet? Tweeting on matters of such import is unpresidential, not to mention unmanly. Also, it’s insane !

I could pause here and write verbatim the emails and social-media comments certain to follow these observations. They’re as predictable as a 3 a.m. tweet from Trump Tower. This, too, is part of what’s frightening as we take our leave of 2016. People who voted for Trump refuse to critique his behavior through any lens but that of having won a contest.

“We won, you lost — get over it” is what now passes for a serious dialogue about matters of immense importance.

The notion that people who still express concerns — including three professors of psychiatry who’ve signed a letter suggesting the man isn’t well — are just sore losers is nonsense. When the president-elect of the United States so cavalierly threatens to unravel the fragile threads that hold civilization together, there are no winners. He or she who is not worried is not paying attention.

These are also not simple partisan fears. Many Republicans I know are “slightly terrified,” as one Trump voter recently put it to me. That most, if not all, Democrats are, too, doesn’t have to mean they’re all excessively disappointed, though many surely are. And when it comes to abusing logic, Trump wins hands down.

With three children of my own and five young grandchildren I am truly terrified what their future may be given that we are about to have a narcissistic sociopath sworn in as president.  #NotMyPresident. 

 

Trump Coal Country Voters Worry about losing Obamacare

In my view, a column in the Washington Post takes a far too sympathetic view of coal country voters who backed Donald Trump by large margins who now worry that they will lose Obamacare benefits and health care coverage in general.  Pleas that they did not believe Trump would really follow through on his promise to repeal Obamacare defy belief.  All these low information - and seemingly low intelligence - voters needed to do is (i) look a Trump's history of lies and dishonest business practices to know he could not be trusted, and (ii) look at the GOP platform and Paul Ryan's agenda as revealed numerous times over the last four or more years.  Truth be told, these voters and whether or not they live or die means nothing to Ryan and Trump. They allowed themselves to be scammed, eagerly believed lies, and, of course, fell for appeals to their bigotry and/or religious extremism. I for one have zero sympathy for these people.  If they suffer now, they need to take a long look in the mirror to see the root cause of their problem. Here are column highlights:

Last night, CNN aired a terrific segment on people from coal country who voted for Donald Trump — but are now worried that his vow to repeal Obamacare will deprive them of crucial protections that enable them to stay afloat financially. This dovetails with other reporting that suggests a lot of Trump voters may be harmed by repeal of the law.

Which raises a question: Did voters such as these know they were voting for this? After all, Trump promised countless times throughout the campaign to repeal the Affordable Care Act, didn’t he? If they are complaining about this now, don’t they have only themselves to blame?

No. I’m going to argue that, while Trump did repeatedly vow repeal, these voters were absolutely right to conclude that he would not leave them without the sort of federal protections they enjoy under Obamacare. That’s because Trump did, in fact, clearly signal to them that this would not happen.

The CNN segment features people who live in Eastern Kentucky coal country and backed Trump because he promised to bring back coal jobs. Now, however, they worry that a provision in the ACA that makes it easier for longtime coal miners with black lung disease to get disability benefits could get eliminated along with the law. That provision shifted the burden of proving that the disability was directly caused by work in the mines away from the victim. Those benefits include financial and medical benefits. Some benefits now also extend to the widows of miners who had black lung disease — or pneumoconiosis, a lung illness associated with inhalation of coal dust — after their husbands die. Other reporting has also confirmed widespread coal country worries about losing these protections.

One man who worked in the mines for 35 years told CNN’s Miguel Marquez:

“When they eliminate the Obamacare, they may just eliminate all of the black lung program. It may all be gone. Don’t matter how many years you got.”

The widow of a deceased miner, who is now trying to get the benefits, said she doesn’t want to see Obamacare repealed, and even suggested Trump may be on the verge of betraying her and others in the region:

“If he don’t come across like he promised, he’s not gonna be there next time. Not if I can help it.”

These coal country residents are not quite in the same situation as many of the law’s other beneficiaries, who are currently gaining access to health coverage due to increased federal spending and regulation. But they are all benefiting from increased governmental intervention under the law designed to expand health care and support to lower-income or sick people who were unable to secure it for themselves under the old system. Many of them would lose these benefits if the law is repealed.

There is some evidence that many of those people voted for Trump. The Wall Street Journal recently demonstrated that rural, aging, and working class counties that went overwhelmingly for Trump also showed large drops in the uninsured rate. Similarly, Gallup-Healthways data shows that among non-college, lower income whites — a Trump demographic — the uninsured rate has dropped 10 percentage points.

 [T]hese coal country voters in the CNN segment were very clear: They don’t want to lose the protections Obamacare grants them. Other reporting has found similar worries in Trump country. Still other reporting has turned up examples of Trump voters who don’t actually believe he’ll take away their Obamacare.

So what did Trump really tell these voters?

Yes, Trump said endlessly that he’d do away with the ACA instantly. Yes, his own replacement plan would leave millions without coverage. But here’s the rub: Trump also went to great lengths to portray himself as ideologically different from most other Republicans on fundamental questions about the proper role of governmental intervention to help poor and sick people without sufficient access to medical care.

Now, Trump and congressional Republicans may indeed end up rolling back protections for millions who voted for him. But if that happens, and these voters do end up feeling betrayed by Trump, they will be right to feel that way — they will, in fact, have been scammed by Trump.

Perhaps, like other scam victims, they should have looked more closely at the fine print. 

 If you choose to believe a documented con-man and liar - who is also a demagogue - you really have no one to blame but yourself.  These voters deserve to suffer the consequences of their own stupidity and bigotry.  Cruel of me?  Maybe.  But given the damage these voters have done to the nation and its future, they need to pay a truly severe penalty. 

Wednesday Morning Male Beauty - Pt 1

Tuesday Morning Male Beauty - Pt 2

Trump’s Unpopularity Threatens His Presidency

If there is any good news to be found as the prospect of "President Trump" gets closer to becoming a reality it is the fact that his widespread unpopularity may hamper his ability to enact his agenda - whatever it might actually be.  Yes, the Republican controlled Congress will move forward on many heinous and dangerous plans, but in the end the fact that Trump received votes from less than a 27% of registered voters and lost the popular vote could come back to haunt him.  Despite his rhetoric and that of his sycophants, he has no mandate.  Not factored into the piece is the reality that much of the Congressional GOP's agenda will prove catastrophic for many Trump supporters who, hopefully, will figure out that they have been betrayed and seek revenge on the GOP in future elections.  A piece in Politico looks at reality even if Trump will not.  Here are excerpts:

President-elect Donald Trump will descend on Washington next month, buoyed by his upset victory and Republican control of Congress to implement his agenda.

But he’s facing a major obstacle: Trump will enter the White House as the least-popular incoming president in the modern era of public-opinion polling.

The down-in-the-dumps figures raise hard questions about whether he’ll have the political capital needed to push through his more controversial nominees and his aggressive legislative goals of repealing Obamacare, passing a major infrastructure spending plan and reforming immigration and tax policies.

On Election Day, just 38 percent of voters had a favorable opinion of Trump, compared to 60 percent who viewed him unfavorably — unheard of for a presidential-election victor.

Trump’s persistent and deep unpopularity – combined with the fact that he lost the popular vote to Hillary Clinton by nearly 3 million ballots – means he lacks the potent argument that the will of the people are behind his agenda.

“He’s clearly not doing as well as other presidents-elect,” said GOP pollster David Winston, a long-time adviser to Republican leaders in both the House and Senate. “We’ve never had a president-elect that had more unfavorables than favorables. He’s started in a pretty big hole in terms of favorables.”

And even though Democrats are in the minority in both chambers of Congress — Republicans will control 241 of 435 House seats and 52 out of 100 Senate seats — the party sees an opening in Trump’s poor poll standing.

“The lack of support for the president-elect means that Democrats can oppose him when they believe they should,” said Jesse Ferguson, the former Democratic Congressional Campaign Committee independent-expenditure head who worked as a spokesman for Clinton’s campaign this year. “They can be confident that there’s no pressure for them to support him out of fear of his political prowess and political power, because his coattails look a little more like a T-SHIRT.”

The outlook for Trump’s nominees is generally positive, but some have already caused agitation not only among Democrats but also among his fellow Republicans. The loudest intra-party dissent has come in reaction to Trump’s nominee for secretary of state, ExxonMobil CEO Rex Tillerson, who has extensive ties with Russia. That has raised the ire of Sens. John McCain (R-Ariz.) and Lindsey Graham (R-S.C.), two notable Russia hawks.

While both chambers of Congress appear daunting for Democrats in the 2018 midterm elections – given the cycle’s Senate map and House districts that favor the GOP every two years – Ferguson said voters who backed Trump in this year’s election can flip if they don’t approve of his job performance two years from now.

That raises the stakes for Trump and the congressional GOP’s first months next year, Winston said. Voters sent a clear message on Election Day: They are eager for action, and they aren’t afraid to rock the boat again in the next election.

“[Voters] want to see things get done,” he added. “Members understand that. They understand that the ball’s now in their court, and they’re going to have to put points on the board. The electorate is looking for things to happen pretty quickly here.”