Repealing the ACA without a Replacement — The Risks to American Health Care
By Barack H. Obama - President of the United States
Health care policy often shifts when the country’s leadership changes. That was true when I took office, and it will likely be true with President-elect Donald Trump. I am proud that my administration’s work, through the Affordable Care Act (ACA) and other policies, helped millions more Americans know the security of health care in a system that is more effective and efficient. At the same time, there is more work to do to ensure that all Americans have access to high-quality, affordable health care. What the past 8 years have taught us is that health care reform requires an evidence-based, careful approach, driven by what is best for the American people. That is why Republicans’ plan to repeal the ACA with no plan to replace and improve it is so reckless. Rather than jeopardize financial security and access to care for tens of millions of Americans, policymakers should develop a plan to build on what works before they unravel what is in place.
Thanks to the ACA, a larger share of Americans have health insurance than ever before. Increased coverage is translating into improved access to medical care — as well as greater financial security and better health. Meanwhile, the vast majority of Americans still get their health care through sources that predate the law, such as a job or Medicare, and are benefiting from improved consumer protections, such as free preventive services.
We have also made progress in how we pay for health care, including rewarding providers who deliver high-quality care rather than just a high quantity of care. These and other reforms in the ACA have helped slow health care cost growth to a fraction of historical rates while improving quality for patients. This includes better-quality and lower-cost care for tens of millions of seniors, individuals with disabilities, and low-income families covered by Medicare, Medicaid, and the Children’s Health Insurance Program. And these benefits will grow in the years to come.
That being said, I am the first to say we can make improvements. Informed by the lessons we’ve learned during my presidency, I have put forward ideas in my budgets and a July 2016 article to address ongoing challenges — such as a lack of choice in some health insurance markets, premiums that remain unaffordable for some families, and high prescription-drug costs. For example, allowing Medicare to negotiate drug prices could both reduce seniors’ spending and give private payers greater leverage. And I have always welcomed others’ ideas that meet the test of making the health system better. But persistent partisan resistance to the ACA has made small as well as significant improvements extremely difficult.
Now, Republican congressional leaders say they will repeal the ACA early this year, with a promise to replace it in subsequent legislation — which, if patterned after House Speaker Paul Ryan’s ideas, would be partly paid for by capping Medicare and Medicaid spending. They have yet to introduce that “replacement bill,” hold a hearing on it, or produce a cost analysis — let alone engage in the more than a year of public debate that preceded passage of the ACA. Instead, they say that such a debate will occur after the ACA is repealed. They claim that a 2- or 3-year delay will be sufficient to develop, pass, and implement a replacement bill.
This approach of “repeal first and replace later” is, simply put, irresponsible — and could slowly bleed the health care system that all of us depend on. (And, though not my focus here, executive actions could have similar consequential negative effects on our health system.) If a repeal with a delay is enacted, the health care system will be standing on the edge of a cliff, resulting in uncertainty and, in some cases, harm beginning immediately. Insurance companies may not want to participate in the Health Insurance Marketplace in 2018 or may significantly increase prices to prepare for changes in the next year or two, partly to try to avoid the blame for any change that is unpopular. Physician practices may stop investing in new approaches to care coordination if Medicare’s Innovation Center is eliminated. Hospitals may have to cut back services and jobs in the short run in anticipation of the surge in uncompensated care that will result from rolling back the Medicaid expansion. Employers may have to reduce raises or delay hiring to plan for faster growth in health care costs without the current law’s cost-saving incentives. And people with preexisting conditions may fear losing lifesaving health care that may no longer be affordable or accessible.
Furthermore, there is no guarantee of getting a second vote to avoid such a cliff, especially on something as difficult as comprehensive health care reform. Put aside the scope of health care reform — the federal health care budget is 50% bigger than that of the Department of Defense. Put aside how it personally touches every single American — practically every week, I get letters from people passionately sharing how the ACA is working for them and about how we can make it better. “Repeal and replace” is a deceptively catchy phrase — the truth is that health care reform is complex, with many interlocking pieces, so that undoing some of it may undo all of it.
Take, for example, preexisting conditions. For the first time, because of the ACA, people with preexisting conditions cannot be denied coverage, denied benefits, or charged exorbitant rates. I take my successor at his word: he wants to maintain protections for the 133 million Americans with preexisting conditions. Yet Republicans in Congress want to repeal the individual-responsibility portion of the law. I was initially against this Republican idea, but we learned from Massachusetts that individual responsibility, alongside financial assistance, is the only proven way to provide affordable, private, individual insurance to every American. Maintaining protections for people with preexisting conditions without requiring individual responsibility would cost millions of Americans their coverage and cause dramatic premium increases for millions more. This is just one of the many complex trade-offs in health care reform.
Given that Republicans have yet to craft a replacement plan, and that unforeseen events might overtake their planned agenda, there might never be a second vote on a plan to replace the ACA if it is repealed. And if a second vote does not happen, tens of millions of Americans will be harmed. A recent Urban Institute analysis estimated that a likely repeal bill would not only reverse recent gains in insurance coverage, but leave us with more uninsured and uncompensated care than when we started.
Put simply, all our gains are at stake if Congress takes up repealing the health law without an alternative that covers more Americans, improves quality, and makes health care more affordable. That move takes away the opportunity to build on what works and fix what does not. It adds uncertainty to lives of patients, the work of their doctors, and the hospitals and health systems that care for them. And it jeopardizes the improvements in health care that millions of Americans now enjoy.
Congress can take a responsible, bipartisan approach to improving the health care system. This was how we overhauled Medicare’s flawed physician payment system less than 2 years ago. I will applaud legislation that improves Americans’ care, but Republicans should identify improvements and explain their plan from the start — they owe the American people nothing less.
Health care reform isn’t about a nameless, faceless “system.” It’s about the millions of lives at stake — from the cancer survivor who can now take a new job without fear of losing his insurance, to the young person who can stay on her parents’ insurance after college, to the countless Americans who now live healthier lives thanks to the law’s protections. Policymakers should therefore abide by the physician’s oath: “first, do no harm.”
Comment by Don McCanne
Senior Fellow, Physicians For A National Health Program
The negative consequences of repealing the Affordable Care Act without replacing it with measures that address some of the problems that ACA was designed to fix have been well publicized. President Obama is right to warn us about repealing ACA without replacing it. But the full story is more complex.
Although the Republicans are moving ahead with including repeal of ACA in the budget reconciliation process, we do not have any details about what is being repealed nor when the repeal would actually take place, if ever. And the Republicans have no clue as to what their replacement would be, especially since it is obvious that their favored proposals such as health savings accounts and selling insurance across state borders would not effectively address the deficiencies that would be recreated by repeal.
Of greater concern, President Obama’s warning about repealing without replacement misses the bigger picture. ACA only tweaked our dysfunctional financing system when we needed comprehensive reform.
Obama touts ACA measures that supposedly saved money by replacing quantity with quality, but, in fact, such measures have not had even a negligible impact on overall cost containment. What they have done is to increase administrative complexity and waste, resulting in an epidemic of physician burnout.
He touts the increase in the numbers of individuals insured, but ignores the deterioration in quality of the coverage through the increase in financial barriers to care, especially high deductibles, and the impaired access that is resulting from expanded use of ever narrower provider networks.
He expresses regret that guaranteeing coverage to individuals with preexisting disorders requires a very unpopular individual mandate to purchase insurance (to prevent adverse selection), and yet he remains silent on the fact that social insurance programs such as Medicare are extremely popular and they rely on automatic coverage instead on an individual decision on whether or not to comply with a mandate.
He repeats the tag line that he used when he rejected single payer reform: we need to “build on what works and fix what does not.” Yet ACA patched only a few problems but did not begin to address the major deficiencies of our health care financing infrastructure, especially those resulting in profound administrative waste. ACA provided tweaks when we needed a new infrastructure.
And then - Primum non nocere - First do no harm. A system in which people are suffering, going broke, and sometimes even dying, is a system which is doing great harm. Reform should not be slogan driven. It should be built on what really does work to actually reduce harm. A single payer national health program - improved Medicare for all - does precisely that.
Democrats embracing Tea Party tactics? That won't work without a new ideology
by Jamie Peck - The Guardian
While Republican lawmakers were colluding with vice president-elect Mike Pence about how best to repeal — and probably not replace — the Affordable Care Act on Wednesday, President Obama held a meeting of his own. Unlike many previous meetings of his, Republicans were not invited. He did not “reach across the aisle.”
Instead, the outgoing president laid out a strategy to oppose Republican efforts to repeal his signature healthcare legislation, a move that could kick up to 30 million Americans off health insurance. That strategy involves pushing the phrase “Make America Sick Again,” refusing to “rescue” Republicans by helping them pass bound-to-be-Randian replacement measures and referring to the resulting disaster as “Trumpcare,” as in: “I would have gotten my leg set by a doctor, but thanks to Trumpcare, I’m using Scotch tape.” The political fallout, he said, must solely hurt the Republicans. (Sounds like someone is finally jumping on the Bernie “time to admit you lied” Sanders train.)
Contrast this with remarks made back in April in which Obama warned his party against becoming too much like the Tea Party. Speaking to a group of law students in Chicago, he worried that Democrats would “stake out positions so extreme, they alienate the broad public.” He’s hardly become Eugene Debs, but it seems he’s come around to a more confrontational strategy. (Funny how your priorities change when you go from quelling a left-insurrection to trying to quell a right one.)
In instructing his party to openly vie for power and engage in the muck of actual politics rather than genteel tinkering, the president became the latest and most high-profile advocate of an idea that’s finally picking up steam in mainstream Democratic circles: copying the Tea Party, a faction which, for better or for worse, was and remains devastatingly effective at carrying out its program.
Beginning immediately after Obama’s 2008 election, a vocal, ideologically-driven minority of “activists” began storming town hall meetings, pressuring Republican representatives to resist Obama no matter what he tried to do and purging their party of anyone deemed insufficiently reactionary. Eight years later they enjoy a unified right-wing government and undisputed dominance of the Republican Party. Gone are the days when Congressional Republicans will let themselves be cucked by compromise. It’s high time the Democrats sunk to their level.
A 23-page Google document titled “Indivisible: A Practical Guide for Resisting the Trump Agenda” has been spreading around Washington faster than John Podesta’s risotto recipe. Written by a group of Congressional staffers who witnessed the rise of the Tea Party firsthand, it lays out a number of practical ways progressive activists and lawmakers can defend the incremental gains of the Obama era using Tea Party tactics, minus the physical intimidation and rabid racism.
Operating on a local level, acting defensively and waging constituent phone call campaigns are all ideas that can easily be appropriated. Considering the razor-thin margins by which Republicans won in many states, it should not be hard to frighten Republican representatives with the prospect of getting voted out.
Activists can also empower (or pressure, as the case may be) Democratic lawmakers to stand up for progressive principles, and this means tugging the political spectrum back to the left. Republicans have long known it’s foolish to start negotiations in the middle. They stake out extreme positions — a six-week abortion ban, a complete gutting of the Office of Congressional Ethics — so they can bargain down to what they actually want — a 20-week abortion ban, a “bipartisan” gutting of the OCE.
In contrast, Democrats said they were open to replacing Obamacare before Congress was even in session, voted to authorize the Iraq War and competed throughout the 1990s to show they could put black people in prison and dismantle the welfare state with the best of them. They let the ACA’s public option fall to the threat of a filibuster from Joe Lieberman, which they could have easily withstood if they’d wanted to. Even now, they deride the Tea Party’s tactics as childish and crass, when the truly crass thing is that 45 million people are living in poverty in the richest country in the world.
Of course, what the Google doc and the president fail to mention is that this only works if the Democrats are progressive in the first place; there can be no left-Tea Party without an organizing ideology. Which brings me to another Tea Party tactic: the purge.
While some Democrats (Elizabeth Warren, logical left-Tea Party choice for DNC chair Keith Ellison) are already reasonably progressive and more can potentially be dragged left by political expediency, many are simply too committed to neoliberal ideology and/or beholden to monied interests to be rehabilitated. Which means some pink-slipping and primary-challenging is in order.
Time travelers from the New Deal era would be confused to learn the leftmost major party’s 2016 nominee for president ran her primary campaign against the $15/hour minimum wage, tuition-free college and single-payer healthcare, deriding these common sense reforms as pie-in-the-sky fancies on the level of Trump’s wall, and only begrudgingly adopting certain elements of them once it became clear the left wing of her party might revolt.
In the general election, Trump exploited establishment Democrats’ longstanding support of labor-opposed trade deals to stake out a leftward position that threw the Clinton campaign for a loop. Despite the benefit of hindsight, many in the party’s leadership still refuse to recognize the role these failures played in their 2016 defeat.
For all the New Democrats’ talk of pragmatism over ideology, it seems the truly practical thing would be to grow some sort of ideological backbone. Those who refuse to do so must be left in the woods.
The good news is that once this happens, progressive activists and lawmakers will be able to use Tea Party’s tactics better than the Tea Party itself, because the left has actual grassroots movements.
Black Lives Matter, Fight For $15 and Bernie Sanders’ remarkable campaign are all examples of regular people coming together to effect change that put the Tea Party’s “grassroots” theatrics to shame.
If these movements have already achieved some modest victories on their own, imagine what they’ll be able to do with the legislative and monetary powers of a newly invigorated Democratic Party at their disposal. What the party may lose in large donations, it will gain in small ones, votes and the ability to fix this mess.
And that’s worth spilling some tea along the way.
Republicans Are Courting Disaster on Health Care
by The Editorial Board - NYT
And so it begins. After six years of posturing and futile votes to repeal the Affordable Care Act, Republicans in the Senate have started a process to erase the most important provisions of the health reform law with a simple majority. Millions of Americans are at risk of losing their coverage.
Republican opponents of the health care law insist that it has failed, though it has reduced the number of uninsured Americans to the lowest level in history. They say that it has driven up costs, though health care costs have risen at a much slower pacesince 2010 than they did in years past. And opponents promise they will somehow make health care cheaper and more readily available, though after all these years of reviling Obamacare they have yet to offer any serious alternative. The reality is that the repeal-at-all-costs crowd is ideologically opposed to any government role in the health care system, though every other advanced economy in the world has embraced some form of government intervention as the only way to manage costs and ensure universal access.
With a narrow 52-to-48 majority in the Senate, Republicans are seeking to evade a Democratic filibuster by instructing congressional committees to draft a budget reconciliation bill to effectively repeal the tax and spending provisions of the A.C.A., gutting the law and increasing the deficit. The House is expected to easily pass a repeal of the A.C.A., since it has already done so dozens of times.
It should perhaps come as no surprise that zealots would resort to using a budgetary maneuver to fundamentally change national policy. But it is still galling, especially because the Republicans have put forward no coherent plan for what would replace the A.C.A. To cope with that rather glaring omission, leaders like the House speaker, Paul Ryan, and Vice President-elect Mike Pence have discussed repealing the law but then delaying its end — claiming political victory while leaving Mr. Obama’s plan largely in place — to give Congress and the Trump administration more time to come up with a replacement.
This is cynical politics, of course, but it is also dangerously irresponsible governance. Most experts and much of the health industry — including trade associations representing insurers, hospitals and doctors — have warned that repealing the law without an adequate substitute could be disastrous. Health insurers that see no long-term future for the law will have little incentive to keep offering plans that it would support. And the health insurance marketplaces set up by the A.C.A. will collapse in much of the country if Republicans repeal the individual mandate to purchase health insurance and get rid of or scale back the subsidies available to help people buy policies.
President Obama and congressional Democrats met on Wednesday to discuss how best to protect the A.C.A. They might start by making the case that Mr. Obama has never quite managed to make for the benefits of the law and the dangers of repeal. In particular, they might highlight the stories of the millions of people who voted for Donald Trump and congressional Republicans and now stand to lose their health insurance. A recent Urban Institute study estimated that 956,000 people in Pennsylvania and one million each in Georgia and North Carolina could lose coverage under a repeal done through a reconciliation bill. Most of them are among the very population Mr. Trump said he was running to give a voice to — nationally, 56 percent of those who would lose coverage are white, and 80 percent of adults who would lose insurance have less than a college degree.
The best hope for protecting the major provisions of the A.C.A. rests with the handful of Republicans in the Senate who hold more common-sense views than right-wing ideologues like Mr. Ryan and Mr. Pence. They include: Susan Collins of Maine, who voted against a similar reconciliation bill the Senate passed in 2015 because it would also have defunded Planned Parenthood; Bob Corker and Lamar Alexander, both of Tennessee, who have said they would prefer to repeal once they can replace it with something else; John McCain of Arizona, who told reporters on Tuesday that “we’ve got to concentrate our efforts to making sure that we do it right so that nobody’s left out”; and Rand Paul of Kentucky, who is concerned that repeal will greatly increase the federal debt.
Republican leaders in Congress and Mr. Trump seem eager to show that they can quickly deliver on their campaign promises. If the good of the country is not enough to give them pause, then they might consult their own political self-interest before stampeding to enact policies that will hurt so many Americans.
Republicans’ 4-Step Plan to Repeal the Affordable Care Act
by Robert Pear - NYT
WASHINGTON — Vice President-elect Mike Pence and the top Republicans in Congress made clear on Wednesday, more powerfully and explicitly than ever, that they are dead serious about repealing the Affordable Care Act.
How they can uproot a law deeply embedded in the nation’s health care system without hurting some of the 20 million people who have gained coverage through it is not clear. Nor is it yet evident that millions of Americans with pre-existing medical conditions will be fully protected against disruptions in their health coverage.
But a determined Republican president and Congress can gut the Affordable Care Act, and do it quickly: a step-by-step health care revolution in reverse that would undo many of the changes made since the law was signed by President Obama in March 2010.
Step 1: Defang the filibuster
The Senate intends to pass a budget resolution next week that would shield repeal legislation from a Democratic filibuster. If the Senate completes its action, House Republican leaders hope that they, too, can approve a version of the budget resolution next week. Whether they can meet that goal is unclear.
The resolution contains seemingly innocuous language, instructing four committees that control health care policy — two in the Senate, two in the House — to draft legislation within their jurisdiction that would cut at least $1 billion from the deficit over 10 years. But that language has real teeth. The legislation produced to meet those instructions can pass the Senate with a simple majority — 51 votes if all senators are present — obliterating the power of the Democratic minority to block it.
Those four committees would have just a few weeks, until Jan. 27, to produce legislation repealing major provisions of the Affordable Care Act. House Republicans have some practice at this, because they have voted more than 60 times since 2011 to repeal some or all of the law.
The budget blueprint will guide Congress but will not be presented to the president for a signature or veto.
Step 2: Add the details
The committees — House Energy and Commerce, House Ways and Means, Senate Finance, and Senate Health, Education, Labor and Pensions — will quickly assemble legislation intended to eviscerate the health care law.
The repeal legislation will be in the form of a reconciliation bill, authorized by the Congressional Budget Act of 1974. Such bills can be adopted under special fast-track procedures. But Senate rules generally bar the use of those procedures for measures that have no effect on spending or revenue. So the legislation, as now conceived, would probably leave the most popular provisions of the health law intact, such as the prohibition on insurers’ denying coverage to people with pre-existing conditions.
Instead, the legislation would:
■ Eliminate the tax penalties imposed on people who go without insurance and on larger employers who do not offer coverage to employees.
■ Eliminate tens of billions of dollars provided each year to states that have expanded eligibility for Medicaid.
■ Repeal subsidies for private health insurance coverage obtained through the public marketplaces known as exchanges.
It could also repeal some of the taxes and fees that help pay for the expansion of coverage under the Affordable Care Act. But some Republicans have indicated that they may want to use some of that revenue for their as-yet-undetermined plan to replace the health care law.
The 2010 law imposed taxes and fees on certain high-income people and on health insurers and manufacturers of brand-name prescription drugs and medical devices, among others. Republicans have not said for sure which taxes they will scrap and which they may keep.
Republicans say they will delay the effective date of their repeal bill to avoid disrupting coverage and to provide time for them to develop alternatives to Mr. Obama’s law. They disagree over how long the delay should last, with two to four years being mentioned as possibilities.
Step 3: The new president’s role
Within days of taking office, President-elect Donald J. Trump plans to announce executive actions on health care. Some may undo Obama administration policies. Others will be meant to stabilize health insurance markets and prevent them from collapsing in a vast sea of uncertainty.
“We are working on a series of executive orders that the president-elect will put into effect to ensure that there is an orderly transition, during the period after we repeal Obamacare, to a market-based health care economy,” Mr. Pence said at the Capitol on Wednesday.
He did not provide details, and Trump transition aides said they had no information about the executive orders. But some options are apparent. The federal government could continue providing financial assistance to insurance companies to protect them against financial losses and to prevent consumers’ premiums from soaring more than they have in the last few years.
Step 4: Find a replacement
Even as they move full speed toward gutting the existing health law, Republicans are scrambling to find a replacement. At the moment, they have no consensus.
Mr. Pence said on Wednesday that the replacement would probably encourage greater use of personal health savings accounts and make it easier for carriers to sell insurance across state lines. Also, he said, it would encourage small businesses to band together and buy insurance through “association health plans” sponsored by business and professional organizations.
Some type of subsidy or tax credit for consumers, to help defray the cost of premiums, is also likely. States would have more authority to set insurance standards, and the federal government would have less.
Mr. Trump has also endorsed the idea of state-run “high-risk pools” for people with pre-existing conditions who would otherwise have difficulty finding affordable coverage.
Many experts have said that repealing the health law without a clear plan to replace it could create havoc in insurance markets. Doctors, hospitals and insurance companies do not know what to expect.
Without an effective requirement for people to carry insurance, and without subsidies to buy it, supporters of the law say many healthy people would go without coverage, knowing they could obtain it if they became ill and needed it.
Democrats in Congress say they will do everything they can to thwart Republican efforts to dismantle the Affordable Care Act. They plan to dramatize their case by publicizing the experiences of people whose lives have been saved or improved by the law.
In the Senate next week, Democrats will demand votes intended to put Republicans on record against proposals that could protect consumers. Defenders of the law also hope to mobilize groups like the American Cancer Society and the American Heart Association to speak up for patients.
The Senate Democratic leader, Chuck Schumer of New York, and the House Democratic leader, Nancy Pelosi of California, are encouraging their colleagues to organize rallies around the country on Jan. 15 to oppose the Republicans’ health care agenda.
And to buttress their case, Democrats are compiling statistics from the White House and from researchers at liberal-leaning groups like the Center on Budget and Policy Priorities, the Commonwealth Fund and the Urban Institute, which warn of catastrophic consequences if the law is repealed.
The G.O.P. Health Care Hoax
by Nicholas Kristof - NYT
This week, President-elect Donald Trump and congressional Republicans began to dismantle Obamacare, and here are the details of their replacement plan:
—— —- —- —- - —— —- —— —- - —- —- — —— —- —— —- —- —- — — - - - - —— —- —- —— —- —- —- - —— —- —— —- - —- —- — —— —- - —- —- — - —- —- — —— —- - —- —- — - —- —-
That captures the nonexistent Republican plan to replace Obamacare. They’re telling Americans who feel trapped by health care problems: “Jump! Maybe we’ll catch you.”
This G.O.P. fraud is called “repeal and delay.” That means repealing the Affordable Care Act, effective in a few years without specifying what will replace it.
If the Republicans ran a home renovation business, they would start tearing down your roof this month and promise to return in 2019 with some options for a new one — if you survived.
And survival will be a real issue. The bottom line of the G.O.P. approach is that millions of Americans will lose insurance, and thousands more will die unnecessarily each year because of lack of care.
The paradox of Obamacare is that it is both unpopular and saves lives. Preliminary research suggests that it has already begun saving lives, but it’s too early to have robust data on the improvements to life expectancy among the additional 20 million people who have gained insurance. It is notable that an Urban Institute study found that on the eve of Obamacare’s start, lack of health insurance was killing one American every 24 minutes.
One careful study found that the Republican health care plan in Massachusetts, which was the model for Obamacare, noticeably lowered mortality rates. For every additional 830 adults covered by insurance, one death was prevented each year.
The American College of Physicians warned this week that the G.O.P. course could result in seven million Americans losing their health insurance this year alone, by causing parts of the insurance market to implode. Back-of-envelope calculations suggest that the upshot would be an additional 8,400 Americans dying annually.
How can insurance make such a difference?
I’ve written about my college roommate Scott Androes, a fellow farm boy from Oregon, who switched careers in 2003 and didn’t buy health insurance on the individual market because it was so expensive. Then in 2011 he had trouble urinating and didn’t see a doctor because of the cost.
By 2012 he had blood in his urine and finally was scared enough that he sought medical help. He had waited too long: He had stage IV prostate cancer.
“I blew it,” Scott told me. “I feel like a damned fool.” He showed immense courage in agreeing to tell his story — despite concern that his legacy would be an article highlighting his foolishness — because he wanted people to understand the human cost of a lack of universal insurance. He died soon afterward.
That’s the system that the Republicans are trying to take us back to.
Americans spend two or three times as much on health care as a share of G.D.P. as other industrialized countries but get worse outcomes. American children are 75 percent more likely to die in the first five years of life than British or German children, according to World Bank data, and American women are twice as likely to die in pregnancy as Canadian women. The reasons have to do partly with American poverty, and partly with the high number of uninsured.
Trump would have you believe that he will keep the popular parts of Obamacare, such as the ban on discriminating against pre-existing conditions, while eliminating unpopular parts like the mandate. That’s impossible: The good and bad depend on each other.
The Trump approach would be like trying to amputate a dog’s rear end so you wouldn’t have to clean up its messes. It just doesn’t work that way.
A full repeal of Obamacare would also worsen the deficit. The Congressional Budget Office said in 2015 that “repealing the A.C.A. would increase federal budget deficits by $137 billion over the 2016-2025 period.” That’s more than $1,000 per American household.
Yes, health policy makes eyes glaze over. But focus on these two points: By broad agreement, the number of people insured will drop if Republicans “repeal and delay,” and more uninsured Americans means more Americans dying. That’s why the American College of Physicians, the American Medical Association and even conservative health care analysts have warned Congress not to repeal Obamacare without stipulating what comes next.
Republicans spent $7 million investigating the deaths of four Americans in Benghazi and ultimately found no evidence of high-level wrongdoing. Now they are rushing toward a scam that may cost thousands of American lives every year.
Trump Is Going After Health Care. Will Democrats Push Back?
by Thedo Scocpol - NYT
Where should Democrats head after their recent electoral rout? As it happens, coming fights about federally subsidized health insurance offer the party a golden opportunity to engage people far beyond its urban strongholds, in communities that will be hard hit by Republican plans to shrink Medicaid, privatize Medicare and eliminate the taxes that pay for Obamacare subsidies.
Donald J. Trump won the Electoral College, and Republicans maintained congressional majorities, because of overwhelming victories in small cities, outer suburbs and rural counties. Yet the president-elect and the Republicans are poised to deliver blows to the social fabric and economic underpinnings of those very communities. Along with Representative Tom Price, Mr. Trump’s nominee for secretary of health and human services, congressional Republicans say they want to move quickly to revolutionize all types of federal health insurance spending, using special procedures that require only 51 votes in the Senate.
Congress will be asked not only to cut the taxes levied on businesses and the rich to finance Obamacare benefits for 20 to 30 million low and middle-income Americans; Republican leaders also plan to slash federal commitments to Medicaid, giving states the authority to shrink this health care program for the poor and elderly. And Republican House members, led by Speaker Paul D. Ryan, seem determined to abolish traditional Medicare insurance for retirees and replace it with “premium vouchers” that would throw older Americans on the mercies of private insurance markets and require them to pay more for their care.
Trump voters will be especially hard hit if just part of this sweeping agenda comes to fruition.
Conservatives often point to poor blacks and Latinos as the primary beneficiaries of federal health insurance programs. But such rhetoric obscures the enormous importance of Medicaid, Medicare and Obamacare subsidies to economically struggling white Americans living in small cities and rural areas. In Pennsylvania, where Mr. Trump narrowly beat Hillary Clinton with overwhelming support outside big cities, about 17 percent of residents are 65 or older, above the national average. Meanwhile, some 16 percent of Pennsylvanians benefit from Medicare, and 18 percent from Medicaid. With the bulk of Medicaid going to elderly and disabled residents, that program is the single largest federal subsidy flowing into the Keystone State.
Repealing the Affordable Care Act would also hit Pennsylvania hard. Under the act, some 468,000 low-income Pennsylvanians had gained Medicaid coverage by August 2016, and another 439,000 bought private coverage on the Obamacare marketplace, with more than three-fourths of those people getting tax credits averaging $251 per month. Health care is often sparse in nonurban areas, and the providers that do exist depend on federal insurance programs that help many patients pay for care. If radical Republican cutbacks in federal contributions to health insurance are enacted, Pennsylvania hospitals and health care businesses will lose vital revenues, leaving many lower-income and sick Pennsylvanians at risk of losing access to care.
This is the case in other states as well, meaning many rural and small-town Trump supporters may soon see that Make America Great Again means accelerating economic decline and social devastation. Mr. Trump shows little understanding of the intricate interplay of subsidies and rules in the health care system, and probably has no inkling that federal taxes collected from liberal states like California, Massachusetts and New York heavily subsidize vital health services, businesses and family benefits in the very places that voted heavily for him. In delegating plans for huge health care cutbacks to hard-right congressional Republicans, he will be hurting his own base.
But will Mr. Trump suffer repercussions if the Republican Congress plows ahead? Its proposed changes are unpopular — including repealing the Affordable Care Act, which only one in four Americans support — and eliminating benefits usually arouses anger in the affected groups. But political punishment will not be automatic, because Democrats currently have little organized presence outside urban areas. Small cities and rural areas are overwhelmingly represented in Congress and state capitols by Republicans, who will do all they can to displace blame.
For the Democratic Party, the coming Republican assault on public health insurance represents a huge political opportunity. But to seize it, the party will have to beef up state committees and place a priority on activating volunteer supporters everywhere — getting people to write messages to local newspapers and social media sites, and reach out to hospitals, health care providers and nonprofits to beat the drums about losses the Republicans are inflicting. Even if Democrats cannot soon win outright majorities beyond their urban base, they must be actively involved in communities damaged by Mr. Trump’s false campaign promises.
Democrats cannot just defend Medicare; they must loudly point out that repealing Obamacare means eliminating the taxes that subsidize health care for low- and middle-income people. That huge and immediate tax cut for the rich would lead to the demise of subsidized health insurance for millions of less privileged Americans in rural, suburban and urban communities. Proclaiming this truth could help Democrats gain a new hearing from many Trump voters. But it remains to be seen whether the party can rise to the challenge of showing up everywhere.
The Health Care Plan Trump Voters Really Want
by Drew Altman - NYT
This week Republicans in Congress began their effort to repeal and potentially replace the Affordable Care Act. But after listening to working-class supporters of Donald J. Trump — people who are enrolled in the very health care marketplaces created by the law — one comes away feeling that the Washington debate is sadly disconnected from the concerns of working people.
Those voters have been disappointed by Obamacare, but they could be even more disappointed by Republican alternatives to replace it. They have no strong ideological views about repealing and replacing the Affordable Care Act, or future directions for health policy. What they want are pragmatic solutions to their insurance problems. The very last thing they want is higher out-of-pocket costs.
The Kaiser Foundation organized six focus groups in the Rust Belt areas — three with Trump voters who are enrolled in the Affordable Care Act marketplaces, and three with Trump voters receiving Medicaid. The sessions, with eight to 10 men and women each, were held in late December in Columbus, Ohio, Grand Rapids, Mich., and New Cumberland, Pa. Though the participants did not agree on everything, they expressed remarkably similar opinions on many health care questions. They were not, by and large, angry about their health care; they were simply afraid they will be unable to afford coverage for themselves and their families. They trusted Mr. Trump to do the right thing but were quick to say that they didn’t really know what he would do, and were worried about what would come next.
They spoke anxiously about rising premiums, deductibles, copays and drug costs. They were especially upset by surprise bills for services they believed were covered. They said their coverage was hopelessly complex. Those with marketplace insurance — for which they were eligible for subsidies — saw Medicaid as a much better deal than their insurance and were resentful that people with incomes lower than theirs could get it. They expressed animosity for drug and insurance companies, and sounded as much like Bernie Sanders supporters as Trump voters. One man in Pennsylvania with Type 1 diabetes reported making frequent trips to Eastern Europe to purchase insulin at one-tenth the cost he paid here.
Surveys show that most enrollees in the Affordable Care Act marketplaces are happy with their plans. The Trump voters in our focus groups were representative of people who had not fared as well. Several described their frustration with being forced to change plans annually to keep premiums down, losing their doctors in the process. But asked about policies found in several Republican plans to replace the Affordable Care Act — including a tax credit to help defray the cost of premiums, a tax-preferred savings account and a large deductible typical of catastrophic coverage — several of these Trump voters recoiled, calling such proposals “not insurance at all.” One of those plans has been proposed by Representative Tom Price, Mr. Trump’s nominee to be secretary of Health and Human Services. These voters said they did not understand health savings accounts and displayed skepticism about the concept.
When told Mr. Trump might embrace a plan that included these elements, and particularly very high deductibles, they expressed disbelief. They were also worried about what they called “chaos” if there was a gap between repealing and replacing Obamacare. But most did not think that, as one participant put it, “a smart businessman like Trump would let that happen.” Some were uninsured before the Affordable Care Act and said they did not want to be uninsured again. Generally, the Trump voters on Medicaid were much more satisfied with their coverage.
There was one thing many said they liked about the pre-Affordable Care Act insurance market: their ability to buy lower-cost plans that fit their needs, even if it meant that less healthy people had to pay more. They were unmoved by the principle of risk-sharing, and trusted that Mr. Trump would find a way to protect people with pre-existing medical conditions without a mandate, which most viewed as “un-American.”
If these Trump voters could write a health plan, it would, many said, focus on keeping their out-of-pocket costs low, control drug prices and improve access to cheaper drugs. It would also address consumer issues many had complained about loudly, including eliminating surprise medical bills for out-of-network care, assuring the adequacy of provider networks and making their insurance much more understandable.
Several states are addressing the problem of surprise medical bills. But other steps urged by these Trump voters will be harder to achieve, including controlling drug costs. Republican health reform plans would probably increase deductibles, not lower them. And providing the more generous subsidies for premiums and deductibles that these voters want would require higher taxes, something the Republican Congress seems disinclined to accept.
In general, the focus among congressional Republicans has been on repealing the Affordable Care Act. There has been little discussion of the priorities favored by the Trump voters who spoke to us. But once a Republican replacement plan becomes real, these working-class voters, frustrated with their current coverage, will want to know one thing: how that plan fixes their health insurance problems. And they will not be happy if they are asked to pay even more for their health care.
Republicans are about to feel Obama’s pain on Obamacare — and he knows it
by Aaron Blake
Fight over the future of Obamacare kicks off on the Hill
Play Video2:29
President Obama and Vice President-elect Mike Pence each met with lawmakers from their parties, Jan. 4, to discuss plans for the Affordable Care Act. (Video: Sarah Parnass/Photo: Matt McClain/The Washington Post)
President Obama made a very good political point about Obamacare on Wednesday. So did his successor.
Obama told Democrats at a closed-door meeting that they shouldn't "rescue" Republicans by helping them replace Obamacare after they've dismantled it. Trump meanwhile, tweeted a few pointers himself:
Republicans must be careful in that the Dems own the failed ObamaCare disaster, with its poor coverage and massive premium increases......— Donald J. Trump (@realDonaldTrump) January 4, 2017
massive increases of ObamaCare will take place this year and Dems are to blame for the mess. It will fall of its own weight - be careful!— Donald J. Trump (@realDonaldTrump) January 4, 2017
It's difficult to know exactly what Trump is arguing here, or whom his advice is directed at, but the operative phrase is in there twice: "Be careful."
That's because repealing Obamacare is a difficult and fraught exercise, for a whole host of policy and political reasons. Such is the case when you're trying to get rid of a massive piece of bureaucracy — and especially one with benefits people have already become accustomed to.
Which is why Obama is telling Democrats to force Republicans to replace the law themselves. Sen. Chris Murphy (D-Conn.) said it more bluntly: “If they want to break this, they own it." They know repealing and replacing the law is a very difficult proposition for Republicans — hence the GOP's decision to delay full repeal for as many as three or even four years — and that the promise of Democratic cooperation would only embolden the GOP's repeal efforts. (Right now, the GOP is taking a piecemeal approach.)
They also know, as Paul Kane notes, that Republicans will own the result if things go sideways — just as they did for the past seven years. Better to let the GOP take their own crack and pay the price, the logic goes.
But why is this all so difficult for the GOP?
First, there are the mechanics of actually passing a repeal and a replacement. Our own Mike DeBonis and Kelsey Snell tackled this a couple days ago. Here's the crux:
Democratic opposition and complex Senate rules mean that core pieces of the 2010 health-care overhaul are likely to remain, including the legal framework for the individual mandate and pieces of the state exchanges the law created. ...The rush to immediately chip away at Obama’s regulatory and domestic policies through the complex process known as budget reconciliation could create months of messy GOP infighting. The plan to vote now on repeal and work out the details later means Republican leaders will be slogging through the difficult process of writing a health-care replacement while simultaneously trying to scale back regulations in areas such as clean air and immigration, and possibly tackling a tax-code overhaul. It will be the first real test of how effective the GOP-controlled Congress will be.
Second is the challenge of getting the policy right and avoiding the pitfalls that come with deconstructing and then reconstructing such a big law over time. Gary Claxton, an analyst at the nonprofit Kaiser Family Foundation, compares Obamacare to a stool, in which the unpopular parts of the law are helping prop up the more popular parts.
For example, if Republicans want to get rid of the individual mandate (and they do) while keeping the popular requirement that insurers cover pre-existing conditions, Claxton said, "it would blow up the insurance market" because insurers would be required to accept unhealthy people without also mandating healthy people sign up, as Obamacare does.
"The longer the period between repeal and replace is, the more the market unravels," Claxton said. "And you've blown up the bridge behind you, and you're heading into battle, you can't go backwards. You've gotta figure it out, or else things get really bad."
The third obstacle is the politics: specifically, the idea of taking benefits away from millions of Americans, whether deliberately or because the GOP fails to install an adequate replacement. Obamacare would have been much easier to repeal had it never been implemented in the first place. But today, 20 million Americans have signed up and many other Americans have come to enjoy parts of Obamacare such as the requirement for insurers to cover pre-existing conditions and the option of keeping children on their parents' health-care plan until they turn 26.
Republicans and Trump have said they'd like to keep these latter two legs of the stool, but it's not clear how they'll implement such requirements in ways that are solvent. And even if they can keep those things, you still have the prospect of millions of Americans losing a health-care option they've had for years. There may be plenty of Obamacare recipients who aren't enamored of their fast-rising premiums, sure, but for many it's a health-care option that didn't exist before and could be taken away with an indeterminate replacement.
And indeed, polling suggests even repeal advocates are worried about losing these things. In its November poll, the Kaiser Family Foundation found support for full repeal had declined to 26 percent overall — the lowest in two years. What's more, once you noted to repeal opponents that this could end coverage for pre-existing conditions, 38 percent of them changed their minds. And when it was explained that 20 million people could lose their coverage, 19 percent changed their minds.
Battlelines Drawn as GOP Readies 'To Make America Sick Again'
by Andrea Germanos - Common Dreams
Republicans, "beside themselves" with excitement over their new power in Congress and, in less than three weeks, the White House, announced on Wednesday their plans for a swift attack on the Affordable Care Act (ACA), or Obamacare.
Repealing the ACA, said Vice President-elect Mike Pence after meeting with House Republicans, will be the incoming administration's "first order of business," with a goal of getting legislation to President-elect Donald Trump by Feb. 20. House Speaker Paul Ryan (R-Wis.) also spoke at the news conference, and said that the program, which allowed over 20 million Americans to gain health insurance coverage, "is a story of broken promise after broken promise after broken promise."
The Senate on Wednesday also voted "to take the first official step toward repealing President Barack Obama's signature health care law," as CNN reports. The chamber "voted 51-48 Wednesday to begin debating a budget that, once approved, will prevent Democrats from using a filibuster to block future Republican legislation to scuttle the healthcare law," the Associated Press adds.
As expected, Obama on Wednesday also went to Capitol Hill where he held a closed door meeting with Democrats to urge them to fight against Republican efforts to repeal the law and instead "look out for the American people."
"I think the president made a strong point that the individual provisions of the Affordable Care Act are popular and that we know we're right on policy and we have to be able to get this message out to the American people," said Sen. Ben Cardin (D-Md.) following the meeting, The Hill reports. Added Senate Democratic leader Chuck Schumer: "They want to repeal it and then try to hang it on us. Not going to happen. It's their responsibility, plain and simple."
The Republican attack on the ACA, along with planned assaults on Medicare and Medicaid, "would make America sick again and lead to chaos instead of affordable care," Schumer said, invoking Trump's campaign slogan.
The Guardian writes: "The dueling events on Capitol Hill illustrated the high stakes over healthcare reform, seen as Obama’s proudest domestic policy achievement but now facing demolition by a unified Republican government."
DNC chair hopeful Keith Ellison, meanwhile, used his Twitter platform to denounce the Republican attacks on the healthcare program in a series of tweets, saying that the party is "playing politics with your health."
Democrats Appeal for Compromise: Alter, but Don’t Gut, the Health Law
by Thomas Kaplan and Robert Pear - NYT
WASHINGTON — With Republican leaders pressing to dismantle the Affordable Care Act, possibly within weeks, moderate Senate Democrats reached out on Thursday to Republicans, appealing for them to slow down the repeal efforts and let lawmakers try to find acceptable, bipartisan changes to make the existing law work better.
Democrats also had new reason to hope for possible Republican defections after Speaker Paul D. Ryan of Wisconsin said that the repeal measure would cut off federal funds for Planned Parenthood. But for now, Republican leaders are holding firm. Senator Mitch McConnell of Kentucky, the majority leader, denounced the law, President Obama’s signature domestic achievement, as “a lesson to future generations about how not to legislate.”
Well before Republicans seized control of Washington, moderate Democrats and Republicans in the Senate had begun exploring ways to change the law, tempering its impacts on small business, seeking lower-cost insurance options and changing how quickly subsidies to help purchase insurance policies would phase out with rising incomes.
But those efforts were stymied by Republican leaders who had no interest in improving the health law and by Democratic leaders who saw reopening the law as a political Pandora’s box. Now, Democrats have every interest in opening that box as repeal efforts barrel forward, and they would need to peel off only a few Senate Republicans to slow the fast-track repeal movement.
A possible pressure point is the effort to end funding for Planned Parenthood in the same measure that guts the health law. Already, that has raised questions about the support of two Republicans, Senators Susan Collins of Maine and Lisa Murkowski of Alaska.
“We ought to be talking about reform,” Senator Tim Kaine of Virginia, who led the group of Democrats who reached out to Republican leaders, said on Thursday. “And if Republicans want to call it ‘replace’ and we want to call it ‘reform’ or ‘improvement’ — I don’t care what we call it.”
“There’s so much we can improve, but by pushing an immediate repeal through a partisan budget process, we won’t have the opportunity to work together to build on that common ground,” Mr. Kaine, who was the Democratic vice-presidential nominee, added.
Senate Republicans plan to muscle through a budget blueprint next week that clears the way for the repeal of major parts of the Affordable Care Act without the prospect of a Democratic filibuster. The House plans to take up the blueprint as soon as the Senate approves it.
House and Senate committees would then have until Jan. 27 to produce legislation that eviscerates a law that has extended health coverage to 20 million Americans and protected millions more from discriminatory insurance practices. But it has also been plagued by rising premiums and limited insurance company participation.
If Republicans succeed in gutting the law, they would need Democratic help to find a replacement, because the Republicans’ narrow Senate majority would surely face a filibuster of a partisan health bill. “We want their ideas,” Mr. McConnell said. “We want their input.”
But the effort to quickly undo a law that cost the Democrats so much effort and political capital could poison any chance of cooperation later this year.
Senator Chuck Schumer of New York, the Democratic leader, said on Thursday that Mr. McConnell and his colleagues have two options. One, he said, is for Republicans to devise a plan on their own to replace the health care law.
“Or don’t repeal and come talk to us about how to make some improvements,” Mr. Schumer said. “We’re willing to do that.”
For now, though, Republican leaders are in no mood to compromise. Senator John Cornyn of Texas, the No. 2 Senate Republican, dismissed the appeal from the group of Democrats as an “act of desperation.”
“The fact is the wheels have been coming off of Obamacare for a long time now,” he said, adding that he understood that the Democratic senators, “as a political matter,” feel that they need to defend the health care law.
The request for Republicans to slow down and work with them on changing the health care law came in a letter from 13 senators — 12 Democrats and an independent, Angus King of Maine.
Moderate Democrats for years have been suggesting changes in the Affordable Care Act, based in part on complaints they were hearing from constituents.
In 2014, for example, Senators Heidi Heitkamp of North Dakota and Mark Warner of Virginia, both Democrats, proposed a lower-cost, high-deductible option — a “copper plan,” to go along with bronze, silver, gold and platinum plans already available under the law. Both signed Mr. Kaine’s letter.
As a possible model for bipartisan cooperation, senators pointed to a bill signed by Mr. Obama in October 2015 that protected small and midsize businesses from increases in health insurance premiums. Senators Jeanne Shaheen, Democrat of New Hampshire, and Tim Scott, Republican of South Carolina, led efforts to pass that bill. Ms. Shaheen also signed Mr. Kaine’s letter.
White House officials said Mr. Obama did not particularly like that legislation but signed it after it won broad bipartisan support.
As Republicans moved ahead with their plans for repeal, the Planned Parenthood issue began picking up steam after Mr. Ryan said on Thursday that the health law repeal measure would cut off funds for the organization.
Such a provision could trouble moderate Senate Republicans whose votes are critical to passing repeal legislation.
“Yes, I’d have concerns,” Ms. Murkowski said. “I’ve long been a supporter of Planned Parenthood.” But Ms. Murkowski said she did not know, without seeing a bill, if cutting the funding would be enough to cause her to vote against the health care repeal.
In 2015, Ms. Collins voted against a repeal bill because it would have cut off funds for Planned Parenthood. She expressed hope on Thursday that such a provision would not be in the repeal legislation this year.
In another possible trouble spot, members of the hard-right House Freedom Caucus met on Thursday with Senator Rand Paul, Republican of Kentucky, about the budget blueprint, weighing the possibility of opposing the measure because of its increases in federal spending and debt.
The group of conservatives has a history of opposing spending measures, often against the wishes of their party’s leaders. Mr. Paul has said he will not support the budget blueprint because it would allow the government to add trillions of dollars to the federal debt in the coming decade.
Editor's Note:
As the preceding article demonstrates, some people never learn. Tinkering with and further watering down the fundamentally flawed ACA will neither fix its problems or satisfy the Republicans. The ACA should be replaced by expanding and improving Medicare for all.
-SPC
Conservatives ready to support $1 trillion hole in the budget
by Kelsey Snell and David Weigel - Washington Post
Some of the most conservative members of Congress say they are ready to vote for a budget that would — at least on paper — balloon the deficit to more than $1 trillion by the end of the decade, all for the sake of eventually repealing the Affordable Care Act.
In a dramatic reversal, many members of the hard-line House Freedom Caucus said Thursday they are prepared later this month to support a budget measure that would explode the deficit and increase the public debt to more than $29.1 trillion by 2026,figures contained in the budget resolution itself.
As they left a meeting with Sen. Rand Paul (R-Ky.) on Thursday, some of the conservatives said that spending targets contained in the budget for fiscal 2017 are symbolic. The real goal of the budget legislation, they argued, is to establish an opportunity to finally make good on GOP promises to repeal President Obama’s signature domestic achievement.
“I just came to understand all the different ideas about where we go next,” said Rep. David Schweikert (R-Ariz.), a member of the House Freedom Caucus that typically opposes massive spending increases. Schweikert now says he will probably vote for the budget resolution.
The growing conservative consensus comes nearly one year after the approximately 40-member group announced it would rather torpedo the entire budget process than vote for a fiscal blueprint that increased spending without balancing the budget.
But fiscal discipline now seems to be taking a back seat to the drive to repeal Obamacare.
“I’d like to see a replacement on Obamacare pretty quick,” said Rep. Brian Babin (R-Tex.). “Would I like to see [the budget] balance? Certainly. Absolutely. I’ve got 13 grandchildren, and I don’t want to see them buried under $30 trillion of debt.”
The Freedom Caucus has not taken an official position on the budget — 80 percent of them need to agree to do so — but many members said the dramatic spending increases created in the 2017 budget measure were only technicalities. They contend that voters understand some sacrifices need to be made to gut the health-care law.
Freedom Caucus Chairman Mark Meadows (R-N.C.) told reporters that the group will decide Monday on an official position on the budget.
“The real question is: Does it change the top line number on what we’re spending?” Meadows said. “Does it increase spending — or does it become a vehicle that maintains our current spending levels and allows us to repeal” the Affordable Care Act?
Other Republicans, including Paul, still question whether it is ever acceptable to support deficit increases, no matter how symbolic. Paul described Thursday’s meeting, which attracted 23 Freedom Caucus members and Rep. Thomas Massie (R-Ky.), as a first step.
“I wanted to make sure that conservatives in the House knew that, together, we can have impact and influence on what the budget will be,” Paul said. “I heard one person say that, well, we’ll vote for this now, but we won’t in four months. My point is that the Republican leadership will come back and say, ‘You already voted for it once; why not vote for it a second time?’ ”
Many in the conservative clique emerged ambivalent about Paul’s argument.
“I’m not staking out a position on the budget just yet,” Babin said after the meeting.
Mainstream Republicans are urging their typically implacable conservative colleagues to turn a blind eye to the spending numbers for now. Republican leaders are using a complicated quirk of the budget process to repeal Obamacare without the threat of a blockade by Senate Democrats.
Budget legislation is considered under special rules in the Senate that allow a simple majority of 50 senators rather than the normal 60 needed for almost everything else. There are 52 Republicans in the Senate this year, and there is virtually no hope that any Democrat would agree to dismantle Obama’s health-care law.
The budget introduced this week in the Senate includes instructions for committees to begin repealing the ACA. GOP leaders want Republicans to focus on language requiring members of four committees to produce bills seven days after Trump’s inauguration that each would save $1 billion over a decade by slashing ACA elements.
Not all conservatives are convinced. Paul is joined by deficit hawks like Rep. Dave Brat (R-Va.) who worry their voters won’t countenance even a seemingly meaningless vote to increase the deficit.
“If you’re going to do a symbolic budget resolution, why not put in a good number?” Brat asked Thursday. “People are very cynical, and I need a message so I can go back home with a straight face.”
The collective shrug from other conservatives is the latest evidence that Paul’s protest would be a familiar, lonely one. His floor speech attacking the budget measure for making no attempts at deficit reduction — it projects a $9 trillion increase in the debt by 2026 — was preempted by statements from Sen. Ted Cruz (R-Tex.), Sen. Mike Lee (R-Utah), and Sen. Marco Rubio (R-Fla.), pledging to vote for the resolution anyway.
That position has made Paul one of very few Republicans still talking about the debt as a national crisis worth building legislation around. During his presidential campaign, which ended after the 2016 Iowa caucuses, Paul made a number of attempts to draw attention to the national debt and to promote his annual plans to balance the budget with steep spending cuts.
Months later, most of the Freedom Caucus — 17 members — voted against the GOP’s 2016 budget on debt-reduction grounds. The new budget resolution makes even fewer concessions on debt reduction. For Republicans who frequently described the debt as a threat to their children’s futures, it’s a difficult sell.
“We want to keep in mind the overall picture, both the deficit and how tired people are Obamacare,” said Rep. Randy Weber (R-Tex.). “I do think there’s a danger of the Republicans actually owning this.”
Repealing Obamacare is wrong. Republicans are even going about repeal the wrong way
Editorial Board - Bangor Daily News
Republicans have been eager to repeal the Affordable Care Act ever since President Barack Obama signed it into law in 2010. Soon, they’ll have the power to do it, and they’ve already laid the groundwork for a quick repeal.
Their current strategy appears to be a quick repeal vote with a future date — several years in the future — for it to become effective and replaced with a different, as yet unknown, plan.
Setting aside the reality that repeal is absolutely wrong, Republicans are pursuing a faulty, fantasy-based strategy for achieving their damaging goal.
The fundamental problem with their approach is that once insurance companies know the Affordable Care Act is going away, they would have no incentive to continue to write plans that comply with the act. As a result, the ACA would essentially be dead and the insurance market in turmoil as soon as the repeal vote takes place. That will leave Americans who buy insurance on the individual market without their current best, and often only, option for affordable and useful insurance coverage.
Politically, Republicans are scrambling to find ways to avoid blame for this meltdown.
“Number one thing [Republicans] have to avoid is putting themselves in a position where Democrats can frighten people — that somehow, they won’t have access to health care because of Republicans,” former House Speaker Newt Gingrich, a close Trump ally, told CNN.
A more basic problem is that many in the GOP, including President-elect Donald Trump, have adopted the narrative that the ACA has been a disaster. It has not been.
Since the law’s passage, 20 million Americans have gained health insurance through the act’s provisions. The percentage of Americans without health insurance has been cut nearly in half, from 16 percent in 2010 to 8.6 percent last year. The decrease in the number of uninsured has been most dramatic among low-income Americans, with a 36 percent reduction among those who earn 138 percent of the federal poverty level.
That means millions of people can now regularly see a doctor rather than waiting until health problems become crises that draw them to the emergency room. This improves lives and saves people money.
More than a quarter of American adults under the age of 65 have pre-existing conditions, such as high blood pressure, diabetes, asthma or cancer. Before the ACA, these people could be denied coverage or charged more. In Maine, 229,000 adults have conditions that would allow insurance companies to deny them coverage without ACA protections, according to analysis by the Kaiser Family Foundation.
By extending health insurance to more Americans, hospitals also benefit. The cost of uncompensated care — treatment a patient is unable or unwilling to pay for — has dropped significantly as a percentage of hospitals’ overall budgets. It was cut in half in states that expanded Medicaid coverage. Maine was not among those states.
The reality of losing their health insurance is scaring many Americans, including some who voted for Trump. “I guess I thought that, you know, he would not do this, he would not take health insurance away knowing it would affect so many people’s lives,” Debbie Mills, an Obamacare enrollee in Kentucky who supported Trump, told Vox. “I mean, what are you to do then if you cannot pay for insurance?”
Mills’ husband is on a waiting list for a kidney transplant, which they cannot afford without health insurance.
For these reasons, some Republicans are wary of a quick ACA repeal without a replacement to put in place at the same time.
Sen. John McCain, for example, told reporters this week that he supports a slower approach to repealing the law. He said he is “always worried about something that took a long time in the making and we’ve got to concentrate our efforts to making sure that we do it right so that nobody’s left out.”
Sen. Susan Collins voiced similar concerns last month. “You can’t just drop insurance for 84,000 people,” Collins told the Portland Press Herald, referring to the number people who have signed up for ACA insurance in Maine.
Sen. Angus King opposes a repeal and has joined moderate Democrats in calling for reasonable bipartisan changes to the law rather than a wholesale gutting. He has also co-sponsored an amendment to stop fast-tracking of an ACA repeal.
The ACA is far from perfect, but it has extended insurance coverage to tens of millions of people who need it. Rather than fulfill a vendetta-driven political agenda, Republicans leaders should slow down and realize that an Obamacare repeal won’t just harm their constituents, but also their political futures.
Fixing the Affordable Care Act is a much more prudent path to take.
Editor's Note -
I agree with this BDN editorial 100% - as far as it goes. But it doesn’t go far enough. Would it have violated journalistic ethics to note that every other wealthy democracy has figured out a way to solve this problem or - heaven forbid - that a simple expansion of Medicare would also have done the trick.
Don’t you think that would have added a great deal of value to the piece?
Don’t you think that would have added a great deal of value to the piece?
-SPC
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