Wednesday, March 22, 2017

Health Care Reform Articles - March 22, 2017

Norway Is No. 1 in Happiness. The U.S., Sadly, Is No. 14.

b Naraj Chokshi - March 20, 2017

Norwegians have one more reason to smile, not that they need it.
After placing fourth last year, Norway is now the world’s happiest country, according to the 2017 World Happiness Report, released on Monday. The Central African Republic was the least happy of 155 countries.
The authors of the report found that a half-dozen socioeconomic factors explain much of the difference in happiness among countries, but that social factors play an underappreciated role. As evidence, they cite periods of substantial economic growth that were nonetheless matched by declining happiness in China and the United States, which ranked 14th.
Even in Norway and several other Nordic countries that dominated the top of the list, economics alone did not explain the high rates of happiness.
“It takes good social foundations and trust,” said John Helliwell, one of the report’s editors and a professor emeritus in the Vancouver School of Economics at the University of British Columbia.
The report was prepared by the Sustainable Development Solutions Network, an international panel of social scientists convened by the United Nations. It was edited by Dr. Helliwell; Jeffrey D. Sachs, a Columbia University economist; and Richard Layard, of the London School of Economics.
The ranking is based on answers to a simple life evaluation question developed decades ago by a social scientist and posed to people around the world between 2014 and 2016 by Gallup, the polling organization:
“Please imagine a ladder, with steps numbered from 0 at the bottom to 10 at the top. The top of the ladder represents the best possible life for you and the bottom of the ladder represents the worst possible life for you. On which step of the ladder would you say you personally feel you stand at this time?”
Humanity is about halfway up the ladder, with an average global score of 5.3, based on hundreds of thousands of surveys conducted by Gallup over those years. The top five countries — Norway, Denmark, Iceland, Switzerland and Finland — all have scores just above or below 7.5. The Central African Republic’s score is nearly 2.7.
The authors found that three-quarters of the variation among countries can be explained by six economic and social factors: gross domestic product per capita (a basic measure of national wealth); healthy years of life expectancy; social support (having someone to rely on during times of trouble); trust (a perceived absence of corruption in government and business); the perceived freedom to make life choices; and generosity (measured by donations).
Still, there are outliers.
In Latin America, life evaluations are about 0.6 points higher on average than would otherwise be predicted by those indicators. East Asian countries have the opposite problem, reporting less happiness than would be expected based on those factors. In both cases, the authors credit, at least in part, cultural differences.
Still, they argue that those six factors explain much of the variation in happiness around the world — and that nations ignore the social factors at their own peril.
Take the United States, which ranked 14th this year. Despite gains in per capita income and healthy years of life expectancy, happiness in the United States declined 0.51 points between the two-year periods ending in 2007 and 2016, they found.
“We’re getting richer, but our social capital is deteriorating,” Dr. Sachs said.
Social support, trust, perceived freedom and generosity all suppress happiness in America. And to offset that drag economically, gross domestic product per capita would have to rise from about $53,000 to $133,000, he argues.
“The country is mired in a roiling social crisis that is getting worse,” he wrote in a chapter dedicated to America’s flagging happiness. “Yet the dominant political discourse is all about raising the rate of economic growth.”
To fix that social fraying, Dr. Sachs argues policy makers should work toward campaign finance reform, reducing income and wealth inequality, improving social relations between native-born and immigrant populations, overcoming the national culture of fear induced by the Sept. 11 attacks, and improving the educational system.

Caring for the Common Good Wins: Norway Ranks World's Happiest Country

But in U.S., happiness is falling and Republican priorities stand to make it worse
by Andrea Germanos - Common Dreams - March 20, 2017
Norway now holds the title of the world's happiest country, according to a new report that also outlines how Republican proposals to gut safety nets, enact tax windfalls for the rich, and attack public education—as well as bipartisan failures in terms of the global war on terror and campaign finance—are making happiness further out of grasp for those in the United States.
The finding comes via the fifth edition of the World Happiness Report, which ranks 155 countries on the variables of income, healthy life expectancy, having someone to count on, perceived freedom to make life choices, freedom from corruption, and generosity. It was produced by the Sustainable Development Solutions Network (SDSN), a United Nations initiative, and was released Monday, the International Day of Happiness.
Norway now holds the number one spot, booting Denmark from the ranking it held for three of the past four years. Norway came in at number four last year.
Joining Norway in the top ten slots are, in order, Denmark, Iceland, Switzerland, Finland, Netherlands, Canada, New Zealand, Australia, and Sweden. It's the same group that made up the top ten countries last year.
Like the other top four countries, Norway ranked high in caring, freedom, generosity, honesty, health, income, and good governance.
At the other end of the spectrum sit Rwanda, Syria, Tanzania, Burundi, and the Central Africa Republican, which rank lowest on the happiness index.
According to lead author John Helliwell, also an economist at the University of British Columbia in Canada, Norway is "a remarkable case in point."
"By choosing to produce oil deliberately and investing the proceeds for the benefit of future generations, Norway has protected itself from the volatile ups and downs of many other oil-rich economies. This emphasis on the future over the present is made easier by high levels of mutual trust, shared purpose, generosity, and good governance. All of these are found in Norway, as well as in the other top countries," Helliwell said.
As for the United States, it has slid down one spot from last year, coming in at number 14, and the country, the report says, is "a story of reduced happiness."
Study co-author, economist, and SDSN director Jeffrey Sachs writes (pdf) that the U.S. suffers not from an economic crisis but a "multi-faceted social crisis."
It is made clear, he writes, by "worsening public health indicators"; "plummeting" trust in government; and "astronomical" income inequality, with "the rise of mega-dollars in U.S. politics" and the "deterioration of America's educational system" helping to fuel "destruction of social capital."
Further abetting that destruction has been the country's reaction following the September 11 attacks, which, Sachs writes, "was to stoke fear rather than appeal to social solidarity" and begin "an open-ended global war on terror, appealing to the darkest side of human nature."
Though the country's "social crisis is widely noted, [...] it has not translated into public policy." Rather, he continues:
Almost all of the policy discourse in Washington, D.C. centers on naïve attempts to raise the economic growth rate, as if a higher growth rate would somehow heal the deepening divisions and angst in American society. This kind of growth-only agenda is doubly wrong-headed. First, most of the pseudo-elixirs for growth—especially the Republican Party's beloved nostrum of endless tax cuts and voodoo economics—will only exacerbate America's social inequalities and feed the distrust that is already tearing society apart. Second, a forthright attack on the real sources of social crisis would have a much larger and more rapid beneficial effect on U.S. happiness.
Addressing the crisis entails enacting campaign finance reform; reducing inequality by expanding the social safety net and funding of health and education; "improv[ing] the social relations between the native-born and immigrant populations"; moving beyond the post-9/11 fear campaign (which he writes, President Donald Trump's "Muslim bans" have been a manifestation of); and making a commitment to improved quality education for all.
"As demonstrated by many countries, this report gives evidence that happiness is a result of creating strong social foundations," Sachs said to the Associated Press. "It's time to build social trust and healthy lives, not guns or walls. Let's hold our leaders to this fact."

A Republican Health Care Bill in Search of a Problem

by NYT Editorial Board - March 22, 2017

Republican leaders in the House have been huddling over the last few days in a frantic search for enough votes to win passage of their proposed revision of Obamacare, in the process making an already flawed bill even worse. One measure of their desperation was a cynical last-minute provision that would shift Medicaid costsfrom New York’s rural and suburban counties to the state government, pleasing upstate Republicans who represent those counties but reducing coverage provided by the state.
Such wheeling and dealing has done nothing to improve a bill that would rip coverage from 24 million people over 10 years, leaving more Americans uninsuredthan if Congress simply repealed the Affordable Care Act, and inspiring an official of the American College of Physicians, which represents 148,000 doctors and medical students, to say on Monday that he had “never seen a bill that will do more harm to health.”
It also reflects a fundamental reality: Unlike President Barack Obama, whose clear objective was to expand access to medical care, the Republicans have no coherent idea or shared vision of what they want to achieve and what problem they mean to solve.
Do they want to cover nearly as many as are covered under the A.C.A.? A few senators, like Susan Collins of Maine and Bill Cassidy of Louisiana, say they do, but a majority from the party are not willing to spend the money that would be needed to do that. Or do they want to significantly reduce government spending and regulation of health care, leaving Americans to navigate the free market on their own? Conservatives like Senator Rand Paul of Kentucky and Representative Mark Meadows of North Carolina are arguing for that, but the rest of the congressional Republicans do not want to go down this treacherous path.
In place of a common vision is a truly unappetizing stew. Modest subsidies to help people buy insurance are the Mini-Me versions of Obamacare policies, so reduced as to be almost completely useless to millions of people, especially older and lower-income people and those in states with high medical costs, such as Alaska, North Carolina and Oklahoma — all of which happen to have voted for Mr. Trump. Another provision is an old conservative hobby horse championed by people like House Speaker Paul Ryan: cutting federal spending on Medicaid, which provides insurance to 74 million poor, disabled and elderly Americans. The main goal here is to cut taxes for the rich, even though the change would devastate beneficiaries, state government budgets and public hospitals.
The bottom line: The Republican proposal would not increase “competition and consumer choice” as Mr. Ryan claims. It certainly wouldn’t deliver on President Trump’s promise of “insurance for everybody.” And it wouldn’t be the full repeal of the A.C.A., or Obamacare, that many Republicans have been promising their base for the last seven years. That is why some hard-liners say they will oppose the new bill, which the House is expected to vote on as early as Thursday.
In a better world, this bill would never have seen the light of day, much less be offered for a vote. It is no fair-minded person’s vision of what the American health care system should look like. It is designed to let Mr. Ryan and Mr. Trump declare that they have driven a stake through the heart of Obamacare, no matter the collateral damage to millions of Americans.

Fewer Americans Would Be Insured With G.O.P. Plan Than With Simple Repeal

by Margot Sanger-Katz - NYT - March 22, 2017
The Congressional Budget Office recently said that around 24 million fewer Americans would have health insurance in 2026 under the Republican repeal plan than if the current law stayed in place.
That loss was bigger than most experts anticipated, and led to a round of predictable laments from congressional Democrats — and less predictable ones from Republican senators, including Bill Cassidy of Louisiana and John Thune of South Dakota, who told reporters that the bill needed to be “more helpful” to low-income people who wanted insurance.
But one piece of context has gone little noticed: The Republican bill would actually result in more people being uninsured than if Obamacare were simply repealed. Getting rid of the major coverage provisions and regulations of Obamacare would cost 23 million Americans their health insurance, according to another recent C.B.O. report. In other words, one million more Americans would have health insurance with a clean repeal than with the Republican replacement plan, according to C.B.O. estimates.
The C.B.O. estimated what would happen after a simple repeal when it considered a bill that Congress passed last year. (President Obama later vetoed that bill.) The bill left parts of Obamacare in place, so the 23 million estimate didn’t come with the kind of detailed analysis that accompanied last week’s score of the American Health Care Act. But the similarity of the two estimates highlights some of the difficulties of the current proposal, both for Democrats, who are strongly criticizing potential coverage losses, and for the repeal-or-die crowd, who hate the structure of this new bill.
“It’s reaffirmed how exceedingly complicated and convoluted the approach the House leadership took,” said Dan Holler, the vice president for communications and government relations at Heritage Action, an advocacy group firmly in the repeal-or-die camp.
Late Monday, House leadership revealed a set of amendments to the bill, which will be considered when the bill comes up for a vote. But, if they are adopted, the changesare unlikely to have major effects on overall coverage numbers. If anything, the changes might lead to a larger increase in the number of Americans without health insurance.
The people who would end up without health insurance are slightly different in the two cases. The current bill would cause more people to lose employer insurance, while a straight repeal bill would most likely cause more people who buy their own coverage to become uninsured. A simple repeal would be worse for Americans with pre-existing conditions, but the current bill would be worse for older Americans who are relatively healthy. Both approaches would lead to major reductions in the number of Americans covered by Medicaid.
The bill that Congress passed in 2016 is the third scenario. It would have kept Obamacare’s major insurance regulations on the books, including its rule that health insurers need to sell insurance at the same price to healthy and sick customers of the same age. It would have removed funding for the expansion of Medicaid, dropped subsidies to help people buy health coverage, and eliminated the individual and employer mandates in the law.
The results of those changes would be drastic: In a decade, 32 million more peoplewould be without health insurance, according to the estimates. The C.B.O. essentially said it was a policy combination that would break the insurance market, resulting in substantially more people losing coverage than gained it under Obamacare.
The kind of full repeal that some Republicans are calling for would, of course, be hard to pass. Even if every member of their caucus supported the approach, most experts believe that repealing Obamacare’s major insurance provisions would require a type of legislation that would be vulnerable to a Senate filibuster, and would thus require at least eight Democratic votes.
All three approaches would result in meaningful reductions in the number of Americans with health coverage. But, in the end, it appears that the long-term effects of the current Republican plan don’t look that different from full repeal.

G.O.P.’s Health Care Tightrope Winds Through the Blue-Collar Midwest

by Abby Goodnough and Jonathan Martin - NYT - March 19, 2017

DEFIANCE, Ohio — James Waltimire, a police officer on unpaid medical leave, has been going to the hospital in this small city twice a week for physical therapy after leg surgery, all of it paid for by Medicaid.
Mr. Waltimire, 54, was able to sign up for the government health insurance program last year because Ohio expanded it to cover more than 700,000 low-income adults under the Affordable Care Act. He voted for President Trump — in part because of Mr. Trump’s support for law enforcement — but is now worried about the Republican plan to effectively end the Medicaid expansion through legislation to repeal the health care law.
“Originally the president said he wasn’t going to do nothing to Medicaid,” Mr. Waltimire said the other day after a rehab session. “Now they say he wants to take $880 billion out of Medicaid. That’s going to affect a lot of people who can’t afford to get insurance.”
As Republicans in Washington grapple with how to meet their promise of undoing the greatest expansion of health care coverage since the Great Society, they are struggling with what may be an irreconcilable problem: bridging the vast gulf between the expectations of blue-collar voters like Mr. Waltimire who propelled Mr. Trump to the presidency, and longstanding party orthodoxy that it is not the federal government’s role to provide benefits to a wide swath of society.
If they push forward the House-drafted health bill, which could come to a vote as early as this coming week, Republicans may honor their vow to repeal what they derided as Obamacare, but also risk doing disproportionate harm to the older, working-class white voters who are increasingly vital to their electoral coalition.
Many of those voters live in small Midwestern cities like Defiance and neighboring Bryan, home of a candy company that makes Dum Dum lollipops but has moved many of its jobs to Mexico. Though unemployment is low in the region, where farmland stretches for miles between towns, the slow erosion of manufacturing has taken a toll, and “what’s left in our communities are lower-paying jobs,” said Dr. Neeraj Kanwal, the president of Defiance Regional Hospital.
The region has voted Republican in presidential contests for decades, but its support for Mr. Trump — he took 64 percent of the vote in Defiance County and an even larger share in most of the surrounding counties — was more resounding than for any candidate since Ronald Reagan. Yet many people here tend to have conflicting values that make repeal of the health law appealing on its face but ultimately hard to swallow.
“People in this community are very conservative. They struggle with the federal budget deficit, and they like the idea of personal responsibility,” said Phil Ennen, the president and chief executive of Community Hospitals and Wellness Centers, which has a 75-bed hospital in Bryan. “But at the same time, we have a lot of friends and family and neighbors who just don’t have a lot going for them. There is a population out there that needs Medicaid. That’s the dilemma.”
It is a daunting paradox for a party that, at least in theory, was once unified around a belief that Washington should be tamed, not empowered. But by winning the White House under the banner of economic nationalism, and carrying a series of Democratic-leaning Rust Belt states, Mr. Trump has left his adopted party struggling to come to terms with the reality of who are now voting for Republicans — and what they expect from their government.
Nearly a million Ohio residents gained coverage under the health care act, either through expanded Medicaid or via the new marketplaces created by the law.
The governor, John Kasich, who has become one of his party’s leading pragmatists, was one of several Republican governors who carried out the Medicaid expansion. Late this past week, he joined some of them in a letter to the congressional leadership requesting that the new health care bill be changed so that the Medicaid expansion is not ended entirely. The state’s Republican senator, Rob Portman, has been among the most outspoken Republican lawmakers expressing concern over any attempt to quickly end the expansion. But the Republican congressman who represents Defiance and the surrounding area, Bob Latta, is an ally of the House leadership and has supported the replacement bill.For all the focus on demands by the party hard-liners that the repeal-and-replace bill be less expansive, there is also rising concern among mainline Republicans from states with large numbers of lower-income whites about a backlash. The group includes Mr. Portman, as well as Senators Lisa Murkowski of Alaska, Tom Cotton of Arkansas, Bill Cassidy of Louisiana and Shelley Moore Capito of West Virginia.
“The folks who Hillary Clinton called the ‘deplorables’ are actually those who want better coverage, who we’d be hurting if we don’t change this bill,” Mr. Cassidy said, noting that Mr. Trump promised “he’d give them better care.”
The senator, a physician who once worked in his state’s charity hospital network, bluntly said that the philosophical debate was over and that his party ought to be pragmatic about how best to create a more cost-efficient and comprehensive health care system.
“There’s a widespread recognition that the federal government, Congress, has created the right for every American to have health care,” he said, warning that to throw people off their insurance or make coverage unaffordable would only shift costs back to taxpayers by burdening emergency rooms. “If you want to be fiscally responsible, then coverage is better than no coverage.”
A new Pew Research Center survey indicated that the number of Republicans making below $30,000 a year who believe the federal government has a responsibility to ensure health coverage for all had risen to 52 percent from 31 percent last year. And while just 14 percent of Republicans who make between $30,000 and about $75,000 last year said the government bore responsibility for health care, now 34 percent of such voters do.
“This is a function of Donald Trump engineering a takeover of the Republican Party,” said Whit Ayres, a longtime Republican pollster. “It was takeover more than assimilation, and this is the eminently predictable result.”
But now that it is Mr. Trump’s Republican Party, those who elected him will expect him to fulfill his campaign commitments.
Few Republicans can appreciate the political challenges of the Affordable Care Act like Davy Carter, a Republican and former speaker of the Arkansas House, who shepherded the law’s Medicaid expansion through his conservative legislature in a state where President Barack Obama was disdained.
“If he doesn’t do what he said he was going to do, it will alienate the very voters that put him in office,” Mr. Carter said, referring to Mr. Trump.
He has a warning for fellow Republicans who represent states with large working-class populations that, like his own, have shifted away from their Democratic roots: They did not change parties because they suddenly became free-market conservatives.
Mr. Trump, who pledged repeatedly on the campaign trail to undo Mr. Obama’s “disastrous” health law, appears torn. He is struggling between the political imperative to fulfill that promise — essential both for symbolic purposes of notching a win and for procedural reasons to go forward with an overhaul of the tax code — and his assurances that “everyone will be covered” under the new system.
“We will take care of our people or I’m not signing it,” he said when pressed in a Fox News interview last week about how his voters might fare.
If Congress moves ahead with the House version of the bill, vulnerable voters might find some allies within the health industry: Hospitals that serve the rural regions in what could be called Trump country would be particularly vulnerable. Their patients tend to be older, poorer and sicker, and their profit margins much narrower, if they make any profit at all.
Mike Abrams, president and chief executive of the Ohio Hospital Association, worries that repeal of the health law could force some hospitals to close. “But honestly,” he said, “even if they didn’t close, they would have to make some decisions that would be unwelcome by the community.”
At Defiance Regional, where Mr. Waltimire, the injured police officer, gets his care, Medicaid provides 22 percent of the revenue, up from 15 percent before the Affordable Care Act took effect. The 25-bed hospital, part of the ProMedica Health System in Toledo, has expanded mental health services and is adding a second medical office building.
Randy Oostra, ProMedica’s president and chief executive, said the Republican proposal to give states a fixed amount of money for each person on Medicaid, instead of a large share of whatever each state needs to spend, would be particularly wrenching.
“It will drive down reimbursement over time, and we’re going to start stripping care away,” Mr. Oostra said. “They may have Medicaid, but it’ll be so stripped down that they basically won’t have coverage.”
For those who get private coverage through the Affordable Care Act marketplaces, the Republican plan would provide tax credits based on age instead of income to help with the cost. Independent analyses have found that people in their 50s and 60s would be especially likely to find coverage unaffordable under the new system, which would also allow insurers to charge older people five times as much as younger ones.
Pegge Sines, 62, of rural Edgerton, Ohio, did not vote for president, but her husband, a longtime factory worker who died of lung cancer in December, was an ardent Trump supporter. They had subsidized private insurance through the health care law that covered virtually all his treatment, she said.
Ms. Sines now pays $222 a month for her insurance from the Affordable Care Act marketplace, with a tax credit of $712 covering the rest. That $8,544 annual subsidy is more than twice the $4,000 annual tax credit she would get under the Republican plan.
An aim of Republican legislation is to reduce private premiums, but Ms. Sines’s son, who along with her other two grown children signed up for Medicaid under the expansion, has been warning that their coverage could be “in trouble,” she said. She cannot believe Mr. Trump would allow that to happen.
“I can’t imagine them not keeping it like it is now,” said Ms. Sines, who runs a group home for the elderly.
Mr. Waltimire said he hoped to return to the police force, and the health benefits it provides, this year. But with no guarantee of good health — he was injured in a fall in 2009 and has had circulatory problems ever since — he also hopes other options remain available.
“It’s kind of hard for me,” he said of having free government coverage. “I’ve always worked all my life. But like my counselor said, sometimes you just have to say thank you and move forward.”
Referring to Mr. Trump, he added, “I hope he makes it so that everybody can afford insurance.”

On Health Law, G.O.P. Faces a Formidable Policy Foe: House Republicans

by Emmrie Huetteman - NYT - March 20, 2017

WASHINGTON — Halfway through Congress’s 2013 summer recess, a letter landed on the desks of House Republican leaders demanding a new strategy to fight “one of the largest grievances in our time.” Give Congress the option to defund the Affordable Care Act, it said, or risk shutting down the government.
Republican leaders condemned the idea, and the 80 House Republicans who signed the letter acquired a nickname, courtesy of the conservative commentator Charles Krauthammer — the “suicide caucus.” But it wasn’t long before a bitter disagreement over the health care law snarled budget negotiations and resulted in a disruptive government shutdown that lasted 16 days. Republicans took the blame.
Three and a half years later, the letter’s recipients — John A. Boehner, then the House speaker, and Representative Eric Cantor of Virginia, the majority leader at the time — are gone, casualties of the take-no-prisoners conservatism it espoused.
Representative Mark Meadows of North Carolina — just a freshman Republican when he wrote that letter — and several of the signers are now part of the hard-line group known as the House Freedom Caucus. True to their “suicide caucus” roots, they pose what is possibly the greatest threat to Republicans’ long-awaited opportunity to scrap former President Barack Obama’s biggest domestic policy achievement.
Panning the Republican plan as “Obamacare Lite,” the Freedom Caucus is gamblingthat its demands will not kill the repeal effort that has been a cause célèbre for all Republicans. And with President Trump’s budget request previewing a bruising round of negotiations just weeks from now, its members appear to be on a collision course with their party’s leadership at both ends of Pennsylvania Avenue.
Facing the prospect that their brand of combative conservatism could prove less appealing to voters than Mr. Trump’s, the group has even expressed a tentative willingness to negotiate on a spending bill that may not immediately reduce the deficit, once a deal-breaking prospect during the Obama administration.
“We are willing to play ball, I think. We’re willing to be open,” said Representative Scott Perry of Pennsylvania, a member of the caucus. “But we’ve got to know it’s a consideration for you because it’s a concern for us.”
Formed in early 2015, the Freedom Caucus threw itself into efforts that year to shut down the Department of Homeland Security over Mr. Obama’s executive orders on immigration, and then the federal government over funding for Planned Parenthood. Increasingly angry at Mr. Boehner’s efforts to quell his restive right wing, they pushed to toss him out. That October, he resigned.
So secretive that it will not disclose the names of its members, but headed by the persistently visible and often affable Mr. Meadows, the roughly three dozen members of the group have positioned themselves as the House’s guardians of conservatism.
But some of their fellow Republicans chafe at what they see as their counterproductive propensity to engage in intraparty slugfests. Representative Devin Nunes — the California Republican who in exasperation once called the instigators of the 2013 shutdown “lemmings with suicide vests” — said the refusal to unite sends Republican leaders in search of Democratic votes, “moving the agenda to the left.”
“At the end of the day, this is a team sport,” he said. “On the House side, you have to find a way to pass bills with your majority. No matter what, at all costs, you have to do that.”
House Republicans are keenly aware of the stakes for repealing the Affordable Care Act. About two-thirds of their 237 members were elected in the Tea Party wave of 2010 or later. Most campaigned on getting rid of the health care law.
“This is our generation’s rendezvous with destiny,” said Representative Jeff Duncan of South Carolina, another Freedom Caucus member.
“It’s also a heavy lift,” he added.
Though relatively few House Republicans belong to the Freedom Caucus, the fact that Republican leaders have little margin for error has only emboldened the group. Bills currently need at least 216 votes to clear the House, meaning Republicans can afford to lose just 21 members without Democratic help. (There are five vacancies in the House, four left by Republicans who took cabinet positions in the Trump administration.)
Members of the Freedom Caucus have expressed an assortment of concerns with the health care bill crafted by Speaker Paul D. Ryan and the Trump administration, which they argue does not go far enough toward repealing all aspects of the Affordable Care Act. Among other issues, they have dismissed its subsidies as a new entitlement program, and have argued that the measure should eliminate all essential health benefits requirements placed on insurers to control premiums. They endorsed one member’s plan last month.
They are hardly the only Republicans with concerns about the measure. Representative Ileana Ros-Lehtinen of Florida and a few others in liberal-leaning districts are among other House Republicans who oppose it, as do key Republican governors; many outside groups, including the American Medical Association; and a handful of senators whose concerns clash with conservative opposition in the House.
But the caucus has become the stubborn obstacle to House passage, especially after top members of the Republican Study Committee — a larger conservative group to which some Freedom Caucus members also belong — emerged from a meeting with Mr. Trump Friday morning to say most of them would support the measure. Representative Jim Jordan of Ohio, a founding member of both groups, said he remained opposed.
A planned White House meeting for the Freedom Caucus, featuring pizza and bowling, was postponed last week because of snow.
The fact that “over the past two weeks, the health care bill has gone from take-it-or-leave-it to we’re-open-for-negotiation is proof that the Freedom Caucus is being effective,” said Representative Andy Harris of Maryland, a member of the group.
For a year and a half, Speaker Ryan has navigated the tricky reality that members of his own party present the greatest obstacle to even shared policy goals like repealing the Affordable Care Act — and an existential threat to his speakership.
In October, after Mr. Ryan distanced himself from Mr. Trump when a recording surfaced in which he was heard boasting of sexually assaulting women, members of the Freedom Caucus considered opposing his re-election as the party’s leader. He was later re-elected with almost unanimous Republican support, including from the Freedom Caucus.
Representative Morgan Griffith of Virginia, another member of the Freedom Caucus, shrugged off the idea that the bill’s failure would be an embarrassment for Mr. Ryan.
“People around here get all worked up on, oh my gosh, this is the end of the world,” he said. “Look, the speakership is defined by numerous votes over numerous years. And while you never want to lose when you’re in leadership or speaker, sometimes you’re going to lose. Welcome to legislating.”
Seeing a fellow disrupter in Mr. Trump, members of the Freedom Caucus have embraced him, but it is a risky and tenuous alliance. The group has viewed the willingness to cut entitlements as a practical test of conservatism; Mr. Trump vowed not to touch Social Security or Medicare during his campaign.
Praising Mr. Trump’s proposed increases in military spending, Mr. Harris emphasized that the budget request would not add to the deficit thanks to strikingly deep cuts to social programs and other discretionary funding.
It also would not reduce the deficit. And Mr. Harris, like many Republicans, is concerned that Mr. Trump might make good on his promise for a $1 trillion infrastructure bill.
“You’re never in total agreement,” he said.

Trump Warns House Republicans: Repeal Health Law or Lose Your Seats

by Julie Hirschfeld Davis, Thomas Kaplan and Robert Pear - NYT - March 21, 2012

WASHINGTON — President Trump on Tuesday turned up the pressure on recalcitrant Republicans to support a sweeping bill to overhaul the health care system, threatening wavering lawmakers in his party with political payback if they failed to get behind a measure that has become an early test of his negotiating power.
In a series of meetings and phone calls at the White House and on Capitol Hill, Mr. Trump, Vice President Mike Pence and Republican congressional leaders haggled with holdouts over details as they struggled to assemble a majority to support a bill that would repeal and replace the Affordable Care Act. The legislation is scheduled for a floor vote on Thursday in the House.
But at a private meeting with House Republicans at the Capitol, the president also delivered a blunt warning that many of those present would lose their seats in next year’s midterm congressional elections if the effort failed.
“I’m going to come after you,” Mr. Trump told Representative Mark Meadows, Republican of North Carolina, a prime holdout and the chairman of the conservative Freedom Caucus, a hotbed of concern about the legislation, according to several people in the room who described his comments on condition of anonymity because the session was private. “I believe Mark and his group will come along, because honestly, a loss is not acceptable, folks.”
Mr. Trump told Republicans at the meeting that after voting repeatedly to repeal the health care law and campaigning in 2016 on doing so, they had an obligation to back the bill and would lose their majority if they “blow it,” attendees said.
Despite the day’s feverish efforts — a combination of cajoling, browbeating and horse-trading that recalled Democrats’ efforts to pass the law in 2010 — White House and congressional officials conceded Tuesday that they still lacked the votes to pass the bill. As many as three dozen Republicans remain opposed or unpersuaded, according to one aide with knowledge of the process, who spoke on condition of anonymity to describe internal discussions.
It is not clear whether Mr. Trump would be able to exact a political price from Republicans who opposed the measure; conservative groups including the Club for Growth and Heritage Action for America were lining up against the legislation and pressuring lawmakers to oppose it, raising questions about whether it would be possible to mount a successful primary challenge to defectors. And some Republicans said the political peril would be greater if they supported the health care bill, which they said failed to achieve their goals or those of their constituents.
“I think if we do do this, we lose the majority,” said Representative Mo Brooks, an Alabama Republican and a member of the Freedom Caucus, who said he remained opposed.
Representative Leonard Lance of New Jersey, one of the nearly two dozen Republicans from districts that Mr. Trump lost in 2016, said he was leaning strongly toward a “no” vote. “I campaigned in support of a repeal-and-replace bill that would make health care more affordable and accessible and provide a smooth transition to those who were forced into Obamacare through no fault of their own,” Mr. Lance said. “The bill, as currently drafted, does none of these things.”
It is also not clear whether Mr. Trump, whose popularity has fallen from what was already a historically low point since he took office, is capable of rallying the public behind a plan that is also viewed negatively. Mr. Trump’s approval rating sank to 37 percent in Gallup’s daily tracking poll on Monday. That is only slightly higher than the 34 percent who favor the health measure, according to a Fox News poll last week, compared with 54 percent who were opposed.
The use of a political threat was a classic tactic for Mr. Trump, who keeps a running mental tally of his backers and detractors, and frequently boasts of his efforts to exact revenge from those who have crossed him.
“We’re going to make sure to remember those who stood by us, and who stood by the word that they gave to their voters,” said Sean Spicer, the White House press secretary.
Mr. Trump has not focused on the specifics of the health care bill, arguing in recent days that he is more concerned with pushing it through Congress so he can move on to issues he cares more about, including a large tax cut.
At a fund-raiser for House Republicans on Tuesday night, Mr. Trump said he was eager to cut taxes, but had “no choice” but “to go with the health care first.”
But he has been putting the full power of the White House behind the effort to sell the health bill.
Besides his meeting at the Capitol on Tuesday, he met at the White House with about a dozen members of the centrist Tuesday Group. On Wednesday morning, he is scheduled to meet with members of the Freedom Caucus. Over the weekend, he summoned three prominent conservative critics — Mr. Meadows, Senator Ted Cruz of Texas and Senator Mike Lee of Utah — to his Mar-a-Lago estate in Florida for meetings with Stephen K. Bannon, his chief strategist, to discuss their concerns about the bill.
“He made it very clear he’s all in on this legislation,” said Representative Kevin Brady, Republican of Texas and the chairman of the Ways and Means Committee. “This is a historic moment and a historic promise for Republicans to deliver on this Thursday.”
Speaker Paul D. Ryan was upbeat after the Capitol meeting. “The president just came here and knocked the ball out of the park,” he said. “He knocked the cover off the ball.”
But Mr. Meadows said he was neither bothered nor persuaded by Mr. Trump’s warning that he would lose his constituents’ support if he did not fall in line.
“I believe that I’m representing them in opposing this bill, because it won’t lower premiums,” he said. “Until it does, I’m going to be a ‘no,’ even if it sends me home.”
A prime concern for holdouts was the measure’s lack of provisions to relax federal health insurance regulations that require insurers to provide certain minimum benefits and to spend certain percentages of premium revenues on medical care.
White House officials argued privately that if they included such language in the bill, they would run into procedural problems in the Senate, where the measure is to be considered under special rules that apply to “budget reconciliation” bills. Those rules allow such legislation to be approved with a simple majority — meaning Republicans could push the bill through without any Democratic backing — but to qualify, the provisions must affect spending or revenues.
For other House members, the health bill has been an opportunity to deal. As part of the discussions, Representative Mario Diaz-Balart, Republican of Florida, made it clear to White House officials that he wanted assurances that the president would hold to his pledge to consider reversing President Barack Obama’s opening with Cuba, the White House official said. Mr. Diaz-Balart backed the measure in the Budget Committee last week, although the official said there had been no explicit discussion of trading his vote for a promise on Cuba.
Representative Claudia Tenney, Republican of New York, said she was likely to support the bill after House leaders added a section that would shift Medicaid costs from New York’s counties to the state government.
House leaders also included provisions to allow states to impose a work requirement for certain able-bodied Medicaid beneficiaries, and to allow states to choose a lump-sum block grant to fund Medicaid.
Both of those provisions were meant to win over conservatives, and Mr. Ryan presented the health bill on Tuesday as an improved product that had been refined as much as possible to reflect lawmakers’ concerns — and that now needed to be approved so lawmakers could fulfill their promise to repeal the health law.
“In this day and age, and in this business, in politics, if you get 85 percent of what you want, that’s pretty darn good,” he told reporters.

Republicans trapped by their old attacks on health care
By David Wiegel - Washington Post - March 22, 2017

The vote was looming, and his party was going to lose, but the senator stood up to condemn what the health-care debate had become.
“Even many of the people who support this bill with their votes don’t like it,” he said. “We’re left with party-line votes in the middle of the night, a couple of sweetheart deals to get it over the finish line, and a public that’s outraged.”
The accusations could have come from any Democrat, condemning the battering-ram progress of House Republicans’ American Health Care Act. But they came from Sen. Mitch McConnell (R-Ky.), then the leader of a 40-seat Senate Republican minority, attacking the Affordable Care Act on Christmas Eve of 2009.
Four elections and more than seven years later, the GOP’s push to repeal the ACA has repeated many of the sticky process battles that the party campaigned against. Plans to pass the AHCA in the House on March 23, the anniversary of the ACA’s final passage, emphasize that the GOP is trying to undo in a matter of weeks what Democrats did over a grueling and politically damaging year.
“The ACA took months of deliberations and debate before passage,” said Jim Messina, who was deputy White House chief of staff during the ACA debate. “So the speed and secrecy around the Republican health-care process is pretty shocking, even by Washington standards.”
President Trump met with House Republicans to encourage members to vote in favor of the GOP plan to replace Obamacare. Trump called out Rep. Mark Meadows (R-N.C.) and members of the House Freedom Caucus for not supporting the bill.(Video: Alice Li, Jayne Orenstein/Photo: Matt McClain/The Washington Post)
It’s an especially sore point for Democrats, who spent years defending the ACA from accusations that it had been rammed through. They aimed, early in 2009, to pass a reform bill with bipartisan support. The process dragged through most of the year as Senate Democrats worked to win over Sen. Charles E. Grassley (R-Iowa) and Sen. Olympia J. Snowe (R-Maine), both of whom would vote against final passage.
“What we did, in spite of what they said to the contrary, was hold 26 hearings,” said Rep. James E. Clyburn (D-S.C.), the House Democratic whip during the 2009-2010 process. “We did that for a year. We accepted over 100 Republican amendments. Now here they are, and they won’t accept a single Democratic amendment.”
For years, Republicans not only campaigned against the implementation of the ACA, but explained that Democrats weakened themselves politically by pushing it through. In 2010 and every subsequent election, they decried how Democrats reformed health care with no support from the minority, an original sin that voters could understand.
“We thought — correctly, I think — that the only way the American people would know that a great debate was going on was if the measures were not bipartisan,” McConnell told the Atlantic in 2009. “When you hang the ‘bipartisan’ tag on something, the perception is that differences have been worked out, and there’s a broad agreement that that’s the way forward.”
But the push to pass the AHCA in the budget reconciliation process has left Republicans arguing among themselves, explaining why conservatives should back the bill — not why it would be more broadly popular. Most of House Speaker Paul D. Ryan’s interviews about the bill have been conducted by conservative media outlets, where he’s emphasized its tax cuts and Medicaid caps.

“We’ve been dreaming of this since I’ve been around — since you and I were drinking at a keg,” Ryan told National Review editor in chief Rich Lowry at a forum Friday.
The American Health Care Act falls far short of repealing and replacing the Affordable Care Act, but there are some big potential changes. (Daron Taylor/The Washington Post)
When pressed about the speed of the repeal push, Republicans often insist that Democrats cut more corners.
“None of us are saying what Nancy Pelosi said, her comments about how you had to pass it first,” said Sen. John Barrasso (R-Wy.), one of the Senate’s few doctors, about the Democrat, then the House speaker.
“Folks watching on television now can go online and read what the bill is,” said Office of Management and Budget Director Mick Mulvaney last week. “They can watch the committee hearings. Those are things that were dramatically missing in Obamacare.”
“We’ve allowed the committees to work their will,” White House press secretary Sean Spicer said Tuesday. “The House has taken up the amendment. It’s been online. I mean, there’s always a balance between jamming it down and getting it done and over it, which is how the Democrats operated at one point when they finally moved on their bill, versus how this is done.”
In fact, there were more public debates and committee meetings about the ACA than about the AHCA. In 2009, the House Energy and Commerce Committee held three days of hearings; this year, the committee held one marathon “markup” that went overnight. The text of the earlier bill’s various versions was online for days before each vote. As the Senate closed in on a vote, then-Sen. Tom Coburn of Oklahoma moved, successfully, for the bill to be read in its entirety on the floor. And Pelosi’s accidentally immortal pledge that voters would “find out what’s in” the ACA only after it passed was actually made in March 2010, weeks after the final version of the bill was made public.
Republicans “accuse Dems of ramming through Obamacare,” wrote Philip Klein, a Washington Examiner editor who covered the ACA fight and wrote a book about the law, in a Tuesday tweet. “But Obamacare was passed at the pace of Zootopia DMV sloths compared to this AHCA attempt.”
Additionally, some of the ACA features that the party once railed against also survived in the AHCA. While Republicans have proposed eliminating subsidies, they replaced them with tax credits that some hard-line conservatives view as the same sin. They have adopted a proposal by mainstream New York Republicans to change how the state pays out Medicaid, evoking memories of similar carve-outs that won moderate Democratic support for the ACA.
And the bill keeps cuts to Medicare spending — featured in countless campaign ads — while delaying the “Cadillac tax” on some employer plans until 2025, echoing the “gimmicks” that Ryan once railed against.
“There aren’t that many options,” said Andy Slavitt, acting director of the Centers for Medicare and Medicaid Services under President Barack Obama. “A lot of these are in fact cheap imitations of the ACA that don’t do the job as well.”
This year’s speed also risks unintended consequences, similar to the ones that spawned lawsuits and legislative fixes after the passage of the ACA. Using the budget reconciliation process for what Republicans call the first of three phases to repeal and replace Obamacare allows them to pass their first bill with just 51 votes, but it leaves it open to challenges that it does not meet the “Byrd rule,” which requires such bills to pertain only to budget matters. An amendment, expected to be added on the House floor Thursday to mollify conservatives, changed the language about group plans in a narrow way that might make many veterans ineligible for a tax credit.
“The risk for Republicans in running a much more fast-paced and secretive process is that Republican members will be held accountable for every provision in this legislation — including those added at the last minute that will not fare well with sunlight,” said Messina. “For those voting yes this week, they will face the impossible task of either defending the details that come out or admitting they didn’t take the time to scrutinize such important legislation before it passed. That type of impossible question is one Republican members will face in town halls, editorial boards and interviews for the next 19 months.”
In the meantime, they have gotten stuck in a familiar series of process fights. In January, when Republicans developed the repeal strategy, the message guru Frank Luntz suggested that they frame it as a “rescue” mission for a health-care system that was breaking. Democrats used similar messaging to defend the ACA when it was leaking support. Now, said Luntz, Republicans are experiencing their own drift away from a strategy that worked.
The Daily 202 newsletter
A must-read morning briefing for decision-makers.
“Obamacare promised to lower health-care costs. It didn’t,” said Luntz. “It promised to make health care easier and simpler to access. It didn’t. They promised you could keep your doctor, your hospital, and your health-care plan. It didn’t. This is a simple case to make, yet they aren’t making it. From a communication standpoint, they should be focused on the problem instead of fighting over the solution.”
Democrats, feeling no pressure to bail out the majority party, argue that the backlash is clarifying what they always wanted voters to see in the ACA.
“They’re finding out what’s in it,” said Clyburn. “They love it. Now these guys are trying to take it away from them before they figure out why they love it. Sounds like a couple marriages I know.”
Karen Tumulty contributed to this report.

House Republican health-care plan set to face key hurdle before floor vote
by Mike Debonis, Kelsey Snell and Robert Costa - Washington Post - March 22, 2017

The Republican health-care overhaul spearheaded by House Speaker Paul D. Ryan and backed by President Trump will face a final procedural hurdle Wednesday before leaders put the package on the House floor.
The House Rules Committee will meet to consider the measure and set rules for floor debate that Ryan (Wis.) hopes will come Thursday. The panel will consider a set of changes meant to mollify various blocs of House Republicans and improve the measure’s chances of passing.
Ryan called opposition to the measure part of “the tempest of the legislative process” in a radio interview Wednesday morning with conservative host Hugh Hewitt. He did not rule out that further changes could be made to the bill to win additional votes. But the speaker warned that fulfilling some GOP demands would violate Senate budget rules and leave the bill vulnerable to a blockade by Democrats.
“Those are the kinds of conversations that are ongoing, so I won’t get into ongoing conversations,” he told Hewitt. “We can’t move things that are fatal to the bill even being considered in the Senate.”
Ryan said he remains confident that the measure will pass the House. “This is the one chance we have to actually repeal Obamacare and replace it with the stuff we believe in,” he said, referring to the Affordable Care Act. “The president is all in, we all made this promise, and that’s why I’m confident. People will realize I’m not going to go home and face voters reneging on my word.”
Two weeks after introducing their bill to overhaul the Affordable Care Act to heated criticism, House Republicans unveiled amendments to the plan. Here’s what you need to know about the legislation and its changes. (Bastien Inzaurralde, Sarah Parnass, Jenny Starrs/The Washington Post)
Two dozen GOP lawmakers remained firmly opposed to the health-care overhaul on Tuesday amid a high-stakes persuasion campaign led by Ryan and Trump — more than enough to block the bill. There were also rumblings that a Thursday vote could be delayed if leaders are unable to secure enough votes beforehand.
Trump came to Capitol Hill on Tuesday to sell the measure whose passage would represent a powerful, if symbolic, achievement for both the president and the House speaker. Even if the House approves the package, the legislation faces an uphill battle in the Senate.
In a Tuesday morning address to a closed-door meeting of House Republicans, Trump used both charm and admonishment in selling the GOP plan, reassuring skittish members that they would gain seats in Congress if the bill passed.
He singled out Rep. Mark Meadows (R-N.C.), the chairman of the House Freedom Caucus, which has led the right-wing opposition to the bill.
“I’m gonna come after you, but I know I won’t have to, because I know you’ll vote yes,” Trump said, according to several lawmakers who attended the meeting. “Honestly, a loss is not acceptable, folks.”
Trump’s remarks — which Meadows said he took as good-natured ribbing — reflected his mounting urgency to secure a major legislative victory in the early months of his presidency and fulfill a central campaign promise by repealing the signature domestic achievement of President Barack Obama. Passing a health-care measure is key to unlocking momentum for the president’s other legislative priorities such as tax reform and infrastructure spending.
“He wants to get this bill done,” said Sen. David Perdue (R-Ga.), a Trump ally. “I don’t hear that as a threat. It’s a statement of reality.”
The holdouts are mainly hard-line conservatives who believe the bill, known as the American Health Care Act, does not do nearly enough to undo the Affordable Care Act passed by Democrats in 2010. But they also include moderates who fear the bill will imperil their constituents as well as their party’s prospects at the ballot box.
In interviews on Tuesday, more than two dozen lawmakers said they were either firmly opposed to the bill or leaning toward voting against it. Ryan can lose only 21 members of his own party for the bill to succeed, as no Democrats have pledged to support the package.
Several Republicans privately said that the Thursday vote could be postponed if leaders are unable to secure enough firm votes for passage beforehand.
One top Republican not authorized to speak about the whipping process said the leadership remained confident it will collect enough support but is weighing scheduling options.
“The White House is engaged, the leadership is engaged, everyone is working together,” the Republican said. “But this is the House GOP, and you can’t assume that it’s going to go perfect. You leave options,” meaning a vote on Friday or even the weekend.
A second Republican, also not authorized to discuss internal deliberations, said others in the leadership orbit were eager to bring the bill to the floor even if the count is narrow because they would like opponents to take ownership of their position and the consequences of what it would mean for the president.
Addressing reporters Tuesday, Ryan played down the possibility that the bill could fail Thursday and argued that conservatives should be pleased that many of their demands would probably be in the legislation. Adding further changes, he said, could jeopardize the legislation’s chances in the Senate.
“If you get 85 percent of what you want, that’s pretty darn good,” he said. “We don’t want to put something in this bill that the Senate is telling us is fatal.”
Senate Majority Leader Mitch McConnell (R-Ky.) sounded a cautiously optimistic note Tuesday, promising that the Senate would forge ahead with plans for votes on the measure — if it passed the House first.
“If the House passes something, I will bring it up,” McConnell said. “We’ll try to move it across the floor next week.”
On Tuesday afternoon, Trump hosted more than a dozen members of the Tuesday Group, a moderate House faction, in the Oval Office for a lower-key lobbying session that involved Trump asking each personto relay their concerns about the bill.
On Friday, a similar meeting helped Trump win converts among members of the Republican Study Committee, a key conservative bloc. But on Tuesday, Trump found more resistance.
Going into the White House meeting, Rep. Leonard Lance (R-N.J.) described himself as “a strong lean no,” citing a variety of concerns. “My views are based on fundamentals in the legislation,” he said. “I don’t see the lower premiums in this bill.”
After the meeting, he said his views had hardened: “I’m a no,” he told reporters.
The meeting came less than 24 hours after GOP leaders released changes to the bill that they believe are sufficient to win a House majority.
Many of the changes were made to placate conservatives, including giving states the option to take a fixed Medicaid block grant and to impose work requirements on childless, able-bodied adults covered under the program. Others responded to broader concerns about the sufficiency of the tax credits offered to help Americans purchase insurance.
One revision was more narrowly targeted — added at the behest of a group of Upstate New York Republicans who wanted to end their state’s practice of commandeering local tax revenue to fund state Medicaid benefits.
That compounded the concerns of Rep. Daniel Donovan (R-N.Y.), a Tuesday Group member who represents parts of New York City that would be hurt by the change.
“I have four hospital systems in my district; they are my biggest employers,” he said. “All of them have grave concerns about how they are going to survive if this gets passed.”
After the White House session, Donovan said he welcomed the meeting with Trump but had not reached a final decision: “We’ll know on Thursday. Some of these things have to be addressed.”
One surprising holdout was Rep. Lou Barletta (R-Pa.), who was among the first House members to endorse Trump and has emerged as one of his most stalwart backers. But he is a hard-liner on illegal immigration and cited the issue Tuesday in opposing the bill.
The tax credits offered under the GOP plan, he said, could be claimed by an individual who is not “lawfully in this country and eligible to receive them.”
“I would have a hard time explaining to families in the 11th District . . . why they should be helping to pay for the health expenses of someone who broke the law to get here and has no right to those federal dollars,” he said.
But it was Trump’s warning to Meadows that sent the sharpest message Tuesday. “He was kidding around — I think,” said Rep. Harold Rogers (R-Ky.), a bill supporter.
White House press secretary Sean Spicer said later in the day: “Mark Meadows is a longtime, early supporter of the president. He had some fun at his expense this morning during the conference meeting.”
Asked whether Trump believed that Republicans who opposed the bill would be damaged at the ballot box, Spicer answered: “I think they’ll probably pay a price at home.”
Spicer explained that statement was not a threat but “a political reality.”
Meadows told reporters that he had a “sincere and deep friendship” with Trump and appreciated the many hours of negotiation that were involved in the package. But he remained firmly against the bill absent major changes that Trump and Ryan have now ruled out.
“This is not a personality decision; this is a policy decision,” Meadows said. “It won’t lower premiums, and until it does, I’m going to be a no, even if I sends me home.”
The Freedom Caucus has not taken a formal position to oppose the bill, but it appeared on Tuesday that the bulk of the caucus’s roughly three dozen members stood ready to vote it down.
The Daily 202 newsletter
A must-read morning briefing for decision-makers.
Two caucus members who said they could support the bill — Reps. David Schweikert (R-Ariz.) and H. Morgan Griffith (R-Va.) — both serve on the committees that wrote it.
The others insisted the Freedom Caucus would hold fast. “I personally know of more than 21 House members who are pretty strong no’s,” said Rep. Rod Blum (R-Iowa). “So when [GOP leaders] say they’ve got the numbers, they don’t have the numbers.”
Blum said he was not concerned by Trump’s implied threat that he could face an electoral challenge next year if he opposed the bill: Trump won his northeastern Iowa district by three points, but Blum won it by eight points.
“I outperformed the president, so I’m not worried about that,” he said. “They know who I am, and they know that I care about them, and they know I’ll stand up to my own leadership. I’ll stand up to the president of the United States, I’ll stand up for what I think is right.”

Trump and Ryan: Health Bill May Test Marriage of Convenience

by Matt Flegenheimer and Maggie Haberman - NYT - March 17, 2017

WASHINGTON — President Trump, once the master pitchman for namesake vodka, steaks and now-moldering casinos, seems disinclined to attach his surname to the health care bill some allies have derided as “Ryancare.”
He assured Americans on Thursday of the “improvements being made” to legislation that Speaker Paul D. Ryan initially suggested would scarcely change, amid grumblings that the White House is fuming over the plan’s star-crossed rollout.
And Mr. Ryan, Mr. Trump’s long-wary partner in the endeavor after a year of campaign criticisms and mistrust, is insisting that all is going according to plan. “I would say that there is no intrigue, palace intrigue, divisions between the principals,” Mr. Ryan told reporters on Thursday, allowing that perhaps some “low-level staffers” felt differently.
“We have a president,” he added, brandishing a fluency in the language of Trump, “who likes closing deals.”
For months, the halting union of Mr. Trump and Mr. Ryan has weathered a stark divide in political ideology and style — a mutual acknowledgment, at least so far, that each man was critical to the other’s outsize governing ambitions.
But with the health care bill staggering through the House, its fate uncertain, their alliance is facing an essential test, as White House officials and congressional leaders stare down the prospect of failing at their first major legislative heave.
In less than two months, the party divisions that Mr. Trump exploited in his thundering campaign have resurfaced in the health care fight, even as Republicans control the White House and Congress.
Already, some allies of Mr. Trump are moving to distance him from the potential fallout, privately suggesting that the speaker was never to be trusted in the first place.
Administration officials have expressed frustration that there was not a better explanation of the three-phase approach described by the House Republican leadership after the bill was unveiled, lamenting the resulting confusion.
In recent days, Mr. Ryan has blitzed the news media, including several Trump-leaning outlets often hostile to the speaker, to make the case for the bill more forcefully than the president has seemed interested in doing himself.
But Mr. Ryan has made clear that he alone does not bear the weight of the present challenge.
“It’s not my bill,” he told CNN, noting that the White House had helped Congress draft it. “It’s our bill.” As if for emphasis, he also noted that he talks to the president almost every day.
For the president and the speaker, passage of the bill is about more than the health care debate; it is a matter of demonstrating that major legislation — with the weight of the White House behind it — can sweep through a Republican Congress.
On Capitol Hill, Republicans are already confronting concerns that a stumble on the first major agenda item would imperil future efforts on tax reform and a border wall.
“The legislative window closes a lot sooner than people imagine,” said Peter Wehner, a former director of the White House Office of Strategic Initiatives under President George W. Bush, who has known Mr. Ryan for two decades. “It’s open the first year, and you better get things done. If you win, that builds on itself. And if you lose, that builds on itself.”
In an effort to appease conservatives, the White House is warming to a shortening of the Medicaid phaseout period in the current bill, among other changes, aiming to move the bill through the House and daring moderate Senate Republicans to stand in its way. Soon, Mr. Trump could take to the road himself to pressure potentially reluctant members in their states, according to a person briefed on the discussions.
On Wednesday, Vice President Mike Pence sought to galvanize House Republicans at a closed-door session in the basement of the Capitol, where members dined on Chick-fil-A and sought reassurances. Mr. Pence insisted that Mr. Trump was “spoiling for a fight” to see the process through to completion, according to an attendee.
But while the White House has said publicly that collaboration has been smooth, the bill’s struggles have not gone unnoticed in Mr. Trump’s orbit.
On Monday, a curiously timed report appeared on the pro-Trump website Breitbart, often a repository of tea leaves for members of Mr. Trump’s circle. (It was once run by Mr. Trump’s chief strategist, Stephen K. Bannon, a vocal Ryan critic in his old job.)
Hours after the release of a damaging analysis on the health bill from the Congressional Budget Office, the site published leaked audio of Mr. Ryan telling House members last October that he could no longer defend Mr. Trump’s campaign.
The content of the tape was not news; Mr. Ryan’s view at the time was clear, just after the release of the “Access Hollywood” video in which Mr. Trump boasted of sexually assaulting women. But to admirers of Mr. Ryan, the message of the leak was unsubtle.
“An audience of one,” Charlie Sykes, the longtime Wisconsin radio host and friend of Mr. Ryan’s, wrote on Twitter.
It is not yet clear if the criticisms of Mr. Ryan are resonating with Mr. Trump. The president has been in regular contact with some Republican opponents of the bill in Congress, such as Senator Rand Paul of Kentucky and Representative Mark Meadows of North Carolina, the chairman of the House Freedom Caucus.
And while Mr. Trump has suggested that he will be able to blame Democrats for installing the Affordable Care Act in the first place, some of his advisers are dubious. Mr. Trump has also told people that if this effort fails, he will try again in two years.
Christopher Ruddy, a friend of Mr. Trump’s and the chief executive of Newsmax Media, said the current plan betrays how the president has traditionally viewed government programs.
“Trump should trust his own instincts,” said Mr. Ruddy, who wrote a columnsuggesting that Mr. Trump seek a bipartisan consensus bill.
The administration figure perhaps the most invested in finding a legislative fix is Reince Priebus, Mr. Trump’s chief of staff, who is close with Mr. Ryan.
While in Detroit on Wednesday, Mr. Trump pointed to Mr. Priebus and said he “may one day run a car company or maybe not,” before adding that he was doing a “great job.”
At a later event in Tennessee, after failing to mention the bill earlier in the day, Mr. Trump promised to “repeal and replace horrible and disastrous Obamacare,” repeatedly plugging the current legislation.
Mr. Ryan — who during the campaign called Mr. Trump’s attacks on a judge of Mexican heritage “the textbook definition of a racist comment” — has scarcely said a cross word about him since the election. (He did allow on Thursday that he had “seen no evidence” to support Mr. Trump’s claim that President Barack Obama had wiretapped him.)
The president’s assessment of Mr. Ryan has vacillated at least as much. In 2012, Mr. Trump thought Mr. Ryan was a dangerous choice as Mitt Romney’s running mate, and he was deeply critical of the congressman’s budget proposals to trim entitlement programs.
After Mr. Ryan distanced himself in October, Mr. Trump savaged him as a “weak and ineffective leader.”
But by December, the two had reconciled. At a rally together in Wisconsin, Mr. Trump compared Mr. Ryan to “a fine wine” whose “genius” he had grown to appreciate.
Then came the hedge: “Now, if he ever goes against me, I’m not going to say that.”

Obamacare repeal threatens health programs just as they're starting to work
By Noam N. Levey - LA Times - March 22, 2017

Over the last four years, this city at the foot of the Rocky Mountains has quietly transformed how it cares for its poorest residents.
As hundreds of thousands of Coloradans gained health insurance through the Affordable Care Act, known as or Obamacare, Denver built an extensive new system to keep patients healthy, hiring dozens of mental health specialists and nurses, expanding dental clinics and launching efforts to help patients manage debilitating illnesses, such as diabetes and heart disease.
Now, the model is in jeopardy, just as Denver and other cities nationwide are beginning to reap its benefits.
Republican legislation to roll back Obamacare — slated to be voted on Thursday in the House — threatens to not only strip Medicaid coverage from millions of poor Americans, but also to take away the funding that has allowed communities like Denver to build better systems to care for them.
That is fueling rising alarm in cities such as Los Angeles, Cincinnati, Charleston, W.Va., and Boston, where safety net hospitals have also used the ACA’s insurance expansion to take on underlying challenges that make lower-income Americans sick, including unsafe housing, poor diet and untreated mental illness.
In Denver, the loss of coverage would be devastating, said Dr. Bill Burman, who for the past year served as interim chief executive of Denver Health, the city’s public healthcare system. “The insurance expansion has been absolutely critical to strengthening how we treat our patients. … I don’t think we could absorb those kinds of cuts without paring back.”
Particularly frustrating for Burman and other public health leaders around the country is the prospect that coverage may be stripped away amid growing evidence that this new approach is having an impact.
Denver Health, for example, has seen a slowdown in the growth of emergency room use since the coverage expansion began in 2014, with visits up just 4% between 2013 and 2016. By contrast, ER visits rose 15% in the previous three years.
At the same time, the health system has seen a major uptick in the use of outpatient health services at its clinics, a hopeful sign that patients may be seeking preventive care rather than waiting to rush to the hospital with something more serious.
Between 2013 and 2015, medical visits increased 17%, dental visits rose 32% and mental health visits almost doubled.
Dr. Aaron Hiegert, a dentist at Denver Health’s newest community clinic, which opened last year, said many patients are finally able to get regular care thanks to the insurance expansion.
“We used to just do a lot of tooth pulling,” Hiegert said, because that is what uninsured patients wanted since they couldn’t afford more routine care. “Now we can develop treatment plans for fillings, root canals and other care. … There is so much pent-up demand. It’s unbelievable.”
Addressing dental health — like tackling depression and other mental health issues — can prevent other more serious medical problems.
“Medicaid expansion gave the safety net the resources and the flexibility to innovate,” said Dr. Bruce Siegel, president of America’s Essential Hospitals, an association of hospitals that care for poor patients. “It’s making a difference.”
Denver Health, which traces its origins to the city’s frontier past when the first hospital cared for injured gunslingers, worked for decades to reach patients before they ended up in the emergency room.
Long considered a national model, the medical system developed an extensive network of primary care clinics in low-income neighborhood around the city.
But many uninsured patients, worried about affording even routine care, only sought medical care in an emergency.
That was devastating for patients’ health. It also made it difficult for Denver Health to hire enough nurses, mental health counselors, dentists and others to meet patients’ many health needs.
The Affordable Care Act began to fundamentally change that math.
With hundreds of billions of dollars of new federal aid, many states, including Colorado, extended Medicaid coverage to poor adults with no children, a population not historically eligible for the program. That fueled a nationwide coverage expansion that has driven the U.S. uninsured rate below 9%, nearly half what it was when the law was signed.
At Denver Health, the number of uninsured patients fell by more than 30% between 2010 and 2015. At the same time, the number of patients with Medicaid coverage nearly doubled.
Doctors, nurses and others almost immediately saw a flood of needy patients, many of whom had skipped vital care, sometimes for years.
Jennifer Grote, a Denver Health psychologist, recalled getting called in to help a new Medicaid patient who had refused to get several recommended tests. Grote said the man burst into tears when she explained to him that he wouldn’t have to pay for the tests because he now had health insurance.
The surge of insured patients also meant a shot a revenue for Denver Health, which was already working on ways to build a more comprehensive system of care that could offer patients more than just a 10-minute office visit with an overworked physician.
That meant, for example, putting mental health specialists in the system’s primary care clinics who could work hand-in-hand with doctors on underlying issues like depression that often prevent patients from dealing with their other medical needs.
Altogether, Denver Health has added more than 40 new mental health specialists, pharmacists and so-called navigators, who help poor, very sick patients get needed medical care and support services, such as transportation and in-home assistance.
Denver Health also now has a special clinic for patients who frequently end up in the emergency room, many of whom are homeless and suffer from mental health issues.
Last April, the system opened a new primary care clinic on Denver’s West Side that includes an urgent care center and new dental offices, where Hiegert practices.
And Denver Health added new mental health counselors at its network of 17 school-based clinics.
“We are not seeing patients by ourselves anymore,” said Dr. Jeanne Rozwadowski, a veteran primary care physician at Westside Community Clinic, one of Denver Health’s nine community health centers around the city.
Rozwadowski said particularly frustrating before the ACA had been her limited ability to help poor patients with obvious mental health needs. “I’d say, ‘Here’s a pill. Come back and see me in two weeks,’” she said.
Since the clinic added a mental health counselor, however, Rozwadowski and other physicians and nurses routinely walk their patients down the hall to get extra help.
The new team helped one of Rozwadowski’s diabetic patients, who for years had been unable to control her diet or blood sugar, finally begin working on her health. “It was like she was a new woman,” Rozwadowski said.
For Alejandro Gongora, a 56-year-old auto repairman who gained Medicaid coverage through the healthcare law, Denver Health’s expanded dental services allowed him to get dental implants he never thought possible.
“It’s the best thing that has ever happened to me,” he said. “I feel like I am starting my life again.” Gongora is now back at work.

Why Cystic Fibrosis Patients in Canada Outlive Those in the U.S.

by Aaron Carroll - NYT - March 20, 2017

Cystic fibrosis is an inherited disorder that affects the lungs, pancreas, intestines and other organs. A genetic mutation leads to secretory glands that don’t work well; lungs can get clogged with thick mucus; the pancreas can become plugged up; and the gut can fail to absorb enough nutrients.
Cystic fibrosis has no cure. Over the last few decades, though, we have developed medications, diets and treatments for depredations of the disease. Care has improved so much that people with cystic fibrosis are living on average into their 40s in the United States.
In Canada, however, they are living into their 50s.
recent study published in Annals of Internal Medicine used the Canadian Cystic Fibrosis Registry and the United States Cystic Fibrosis Foundation Patient Registry to determine how patients fared between 1990 and 2013. Researchers compared the longevity results in the two countries, and controlled for a number of factors, including age, sex, genotype, pancreatic status and more.
Over time, they found, the median life span for patients increased. But it increased faster in Canada. Between 2009 and 2013, the median life span was 40.6 years in the United States versus 50.9 in Canada.
One reason might have been that more Canadians with cystic fibrosis received lung transplants (10.3 percent) than their American counterparts (6.5 percent). In Canada, organs are allocated based on length of time on the waiting list. Because people with cystic fibrosis know they may need new lungs long before they become critically ill, they can sign up earlier and be on the list longer before they truly need a transplant. In the United States, organs are allocated based on disease severity; people with cystic fibrosis need to become very ill before they can get a lung, and fewer of them do.
Relatively few cystic fibrosis patients receive lung transplants, however, so it’s unlikely this is the real difference accounting for a decade of life.
Another difference might be nutrition. Older studies comparing cystic fibrosis survival between the two nations showed that aggressive nutritional support with a high-fat, high-calorie diet in the 1970s might have improved prospects for patients in Canada back then. Physicians in the United States instituted more appropriate dietsfor patients after studies in the 1970s and 1980s showed them to be superior, making inadequate nutrition a less likely culprit as well.
Further analysis revealed a much more significant association: insurance.
Canada has a single-payer health care system, which is similar to the American Medicare system. It covers all people in Canada, including those with cystic fibrosis. People in the United States receive their insurance — if they do at all — from a number of sources.
Compared with patients in the United States who had private insurance coverage, patients in Canada had a similar risk of early death. Compared with patients who had public insurance like Medicaid, Canadians with cystic fibrosis had a 44 percent lower risk of early death. And compared with Americans who were uninsured, Canadians had a 77 percent lower risk of early death.
number of factors could be at play. Medications for cystic fibrosis can be expensive, and patients have to take many every day. About 45 percent of American patients with cystic fibrosis receive some form of Medicaid, which can limit the medications patients can get, the providers they can see and the therapies that are covered. For the uninsured, it can be even worse. Insurance, as well as the cost of care, remains a significant concern for people with cystic fibrosis.
No study is perfect, and it’s possible that insurance coverage might just be a marker for socioeconomic status in this analysis. Study after study has shown us that poverty is associated with worse outcomes for many diseases, cystic fibrosis included. Yet the poorest in the United States are more likely to have Medicaid than to be uninsured, and in this study they had better outcomes than those with no insurance at all.
Another fact hints at the power of Canada’s broad health insurance: Canadians tend to live an average of two years longer than Americans. While insurance, and access to the health care system, is certainly not the only factor that affects life expectancy, it’s hard to argue that it’s not at least one factor.
What’s even more compelling is that children and young adults with cystic fibrosis in the United States fare better than their international counterparts on certain health measures. It’s as people age — and, perhaps, as disparities mount — that Americans begin to fall behind.
The United States didn’t always lag in this respect. From 1974 through 1994, cystic fibrosis patients who lived in the United States consistently outlived patients living in other countries in North America, Europe and Australia. Americans have lost that advantage.
It’s easy to repeat the mantra that the United States has “the best health care system in the world.” But a system must be judged on its overall outcomes, and when that is done, America often comes up short.

Medicaid is out of control. Here’s how to fix it.
by Robert J. Samuelson - Washington Post - March 19, 2017

It’s time to take control of Medicaid before it takes control of us. Unless we act — and there is little evidence that we will — Medicaid increasingly becomes another mechanism by which government skews spending toward the old and away from the young. In the raging debate over the Affordable Care Act (Obamacare), this is a subject that neither Republicans nor Democrats dare touch. It’s an ominous omission that obscures the overhaul Medicaid really needs. 
Medicaid is the sleeping giant of U.S. health care. Created in 1965, it provides health insurance for the very poor. Here are some basic Medicaid facts:
● It is the nation’s largest health insurance program by beneficiaries, with 68 million recipients compared with Medicare’s 55 million. (Medicare provides insurance for the 65 and over population.)
● Although the Obamacare debate has focused on private insurance subsidized through health exchanges, the expansion of Medicaid — adopting more liberal eligibility requirements — resulted in the largest gain of insurance coverage, about 11 million people
But the most significant Medicaid fact is this: Although three-quarters of Medicaid recipients are either children or young adults, they account for only one-third of costs. The elderly and disabled constitute the other one-quarter of recipients, but they represent two-thirds of costs
How could this be? Doesn’t Medicare — not Medicaid — cover the elderly and disabled? Well, yes, but there’s a giant omission: nursing home and other long-term care. Medicaid covers these for the poor elderly and disabled. 
Here’s where the past and future collide. As the population ages, the people needing long-term care will soar. From 2015 to 2030, the number of Americans 85 and older will rise about 50 percent to 9 million, projects the Census Bureau. Many will end up in nursing homes, with high costs. The average health costs of Americans 85 and over are 2.5 times greater than for people 65 to 74, says the Center on Budget and Policy Priorities, a research and advocacy group for the poor. 
At the federal level, spending on the elderly — mainly for Social Security, Medicare and Medicaid — is already crowding out nonelderly spending, as the Trump administration’s 2018 budget shows. Now pressures are tightening on states.
Because they pay 40 percent of Medicaid, its escalating costs compete directly with state and local services — schools, roads, police, parks, sanitation — and lower taxes. Medicaid’s “entitlement” nature means that anyone who qualifies for support must get it. By contrast, schools and other state services get what seems affordable. Slowly, Medicaid is usurping state priorities. Medicaid now claims nearly one-fifth of states’ general revenues, reports Robin Rudowitz of the Kaiser Family Foundation. Under present law, the squeeze will worsen. 
Fortunately, there’s a sensible solution to this problem. It isn’t to gut care for the elderly. Instead, we should transfer Medicaid’s long-term care to the federal government, which would pay all costs, probably by merging with Medicare. In return, the states would assume all Medicaid’s costs for children and younger adults, give up some or all of their federal aid for K-12 schools and, if needed, trim other federal grants to ensure financial neutrality. 
At the outset, there would be no obvious winner. For every dollar of higher federal spending on long-term care, there would be a dollar offset in lower spending on medical care for children and younger adults plus less generous federal grants. But over time, this swap of responsibilities would make sense for everyone. It would concentrate oversight for the young at the state and local levels while aid to the elderly and disabled would be firmly lodged at the federal level. 
Consider. For states, spending would no longer be tied to demographic trends — an aging society — they can’t change. Controlling schools and a child-centered Medicaid, they would be in the best position to fight child poverty, which is arguably the nation’s most serious social problem. The rising costs of long-term care, a national problem, would not handcuff them. 
As for the federal government, it would control all major programs for the elderly and disabled. The present splintering is undesirable. It means that a fifth of Medicare recipients are so-called “dual eligibles,” belonging also to Medicaid. This raises costs and complicates caregiving. If benefits for the elderly are to be cut (say, by raising eligibility ages), that job is best done if the federal government can choose from all programs for the old. 
Unfortunately, there is little support for this sort of swap. Commentators (including this reporter) periodically propose it and praise its benefits. But national politicians seem uninterested. They prefer instead to bleed the states.

How Trump Can Fix Health Care

by Benjamin Domenich - NYT - March 21, 2017
President Trump has mostly stayed on the sidelines of the messy policy debates regarding health care reform. But amid the war on Capitol Hill among Republican factions, he could seize the opportunity to provide leadership consistent with his campaign message to disrupt existing health policy.
Instead of trying to satisfy the free-market wing of his party, Mr. Trump could push for a solution that delivers on his populist promises by proposing universal catastrophic coverage, ending the specter of medical bankruptcy for many Americans.
There is little question that the Affordable Care Act replacement legislation proposed by House Speaker Paul Ryan has disappointed many on Capitol Hill, leaving moderates and conservatives alike unhappy and drawing opposition from groups as diverse as the Heritage Foundation and AARP. And even if Mr. Ryan can win passage of this legislation, the Senate will probably rewrite it during the reconciliation process.
During the campaign, Mr. Trump promised that his replacement for President Barack Obama’s signature domestic policy would retain some of the most popular aspects of Obamacare, but do so in a less-expensive way that provides better care. He repeatedly promised that his plan would cover everybody.
The House Republican bill, the American Health Care Act, will not deliver on Mr. Trump’s promises. It represents a real attempt by Speaker Ryan to overhaul entitlements and send authority for Medicaid to the states. What it does not do is try to deliver health insurance to all Americans, as Mr. Trump pledged: Even with hundreds of billions of dollars of refundable tax credits under the plan, 52 million Americans are projected to be uninsured in 2026, according to the Congressional Budget Office.
Mr. Trump won the presidency in part because of some big promises, including a vow to break from conservative orthodoxy on entitlements. If Congress fails to deliver on that promise, Mr. Trump could correct it by going boldly in a direction anathema to many on the right but potentially acceptable to some Democrats: universal coverage for catastrophic care.
Many Americans’ greatest fear is that their health care costs will bankrupt them. The quality of care we receive is high — I experienced this myself this month after a cardiac incident left me reading the Republican plan in an emergency room — but the expense is opaque, and Americans are not wrong to worry about these costs.
By providing catastrophic care for all, President Trump could ensure that everyone has an ultimate backstop against medical bankruptcy, while freeing the states to experiment with options for reform. It would also enable the private sector to offer new insurance products to supplement the basic catastrophic care coverage.
This idea has some support among conservatives. In 2012 Kip Hagopian and Dana Goldman estimated in National Affairs that to insure all 209 million Americans not already covered by public insurance programs would cost about $2,000 per person, or $7,200 per family per year — about half the projected $1.7 trillion cost of Obamacare over the coming decade. Individuals and families could then purchase additional coverage given their particular health needs, but would not be bankrupted by severe illness or accident.
Some on the right may not be comfortable with this plan, given that it would represent a permanent redistributive entitlement. But the House Republican bill also includes a hugely expensive tax credit. This plan would be a straightforward approach to providing insurance against devastating loss that would also render an incredibly complex system of mandates and rules moot, Mr. Hagopian and Professor Goldman argue. That would include ending the requirement that all plans cover pre-existing conditions; the mandate that all individuals buy health insurance; one-size-fits-all “community rating” pricing; and the requirement that insurance companies sell insurance for the same price to everyone regardless of health status.
“Almost all of the costs of these regulations, as well as the negative cost effects of the intrusions into the market that accompany them, would disappear if this plan were in place,” they wrote.
Some on the left may find this kind of plan unacceptable, since universal catastrophic care falls far short of Medicare for all. But Mr. Hagopian and Professor Goldman point out that even catastrophic plans of this sort could cover prenatal care, statin drugs that lower cholesterol and other treatments for chronic illnesses without raising costs for patients.
“If otherwise unaffordable health expenses were covered by insurance and routine health expenses were treated like normal household expenditures, the entire population would be shielded from devastating losses while an efficient consumer market in health care could emerge,” they said.
Given the choice between the House Republican plan or one where all Americans are covered, moderate Democrats would be wise to go along with this solution.
It is obviously not a solution that will satisfy true limited-government conservatives. Any universal benefit along these lines comes with costs that would have to be funded via taxes or debt. But it would be a step consistent with President Trump’s bold message and it could resolve the current debate on Capitol Hill, now headed in a direction unlikely to satisfy anyone.
President Trump has never shied away from thinking big, and now he has the potential to turn the politics of health care upside down with a populist solution that might go a long way toward solving one of the nation’s biggest problems.

Senate Republican holdouts split into rival camps on Obamacare overhaul

by Steven T. Dennis - Bloomberg - March 21, 2017

Republican leaders face a conundrum: If they move the bill to the right, moderates go running; move it to the left, and conservative opponents dig in.

The U.S. House is racing to find enough votes for its health-care bill this week, but even if it passes, prospects in the Senate have only darkened.
More than enough Senate Republicans oppose the House bill to kill it – with rival camps insisting on pulling the bill in opposite directions to meet their demands. With just a 52-48 majority, the bill would fail if three or more Republicans vote against it.
Republican leaders face a conundrum: If they move the bill to the right, moderates go running; move it to the left, and conservative opponents dig in.
Whether Republicans would actually tank something they’ve promised for the past seven years is unclear. All of them say they want something to pass, and House leaders unveiled tweaks to the bill Monday evening.
A look at how Senate GOP opposition to the measure breaks down:

Conservatives demanding fuller repeal

A trio of Senate conservatives has attacked the bill vociferously and said they will not vote for it without changes. At least one of the three – Rand Paul of Kentucky, Ted Cruz of Texas and Mike Lee of Utah – has to vote for the bill for it to pass, given united opposition from Democrats.
Paul, who has libertarian leanings, has slammed the bill as “Obamacare lite.” He criticizes it in part as too generous to people who don’t make enough money to pay income taxes, and has urged conservatives in both chambers to withhold their support for negotiating leverage, citing tactics from Donald Trump’s book “The Art of the Deal.” Trump, in turn, has called Paul on more than one occasion as part of what Paul calls a mutual-wooing operation.
Cruz complains the bill could actually lead to higher premiums next year because it doesn’t repeal Obamacare’s insurance mandates – the most costly of which is a ban on pre-existing conditions – and has tried so far without success to get Republicans to embrace a bolder repeal that would include Vice President Mike Pence overruling the Senate parliamentarian on what can be included in the package under the rules.
“I cannot vote for any bill that keeps premiums rising,” he said Sunday on CBS’s Face the Nation.

Defenders of Planned Parenthood

If McConnell and Trump manage to win over at least one of the members of the conservative trio, they still have numerous hurdles to clear among the party’s moderate camps.
Two Senate Republicans, Susan Collins of Maine and Lisa Murkowski of Alaska, oppose the House bill’s provision defunding Planned Parenthood – enough to bring the bill to the brink.
Defunding Planned Parenthood has been a major Republican priority for years, and losing that provision could cost conservative votes.

Protecting Medicaid expansion

A broader group has expressed concerns about the House’s plans to phase out Medicaid expansion money for their states, including Murkowski, Rob Portman of Ohio, Shelley Moore Capito of West Virginia and Cory Gardner of Colorado.
Dean Heller of Nevada – the Democrats’ No. 1 target in 2018’s midterm elections and the only Republican running in a state won by Hillary Clinton – declared Friday in a statement he couldn’t vote for the House bill as written because of Medicaid concerns expressed by four Republican governors, including Nevada’s Brian Sandoval.
The House bill would phase out that expansion starting in 2020 – part of an larger plan to cut Medicaid by $880 billion and taxes by $883 billion over a decade.
Some conservatives have demanded an earlier phaseout, something that could make it even harder for those senators to support the measure. It also makes potential swing voters out of senators from Arkansas, Nevada, Alaska, Colorado, Ohio and Louisiana – all states that expanded Medicaid.

Other holdouts

Bill Cassidy of Louisiana says he wants to radically reshape the House bill so that it covers more people, not the 24 million fewer estimated by the Congressional Budget Office.
“Society is going to pay for health care whether it is through insurance or not,” he said last week. “Society will pay for it either through cost-shifting to the privately ensured or it will pay for it through enhanced disproportionate payments” to hospitals that treat indigent patients.
Sen. Susan Collins and Sen. Bill Cassidy, R-La., introduced a health care bill in January that would allow states to keep the ACA or choose an option that would provide tax credits that are more generous than those in the plan proposed by House Republicans. Collins says she can’t back the House plan as it standsAssociated Press/J. Scott Applewhite
A doctor who worked for decades in a charity hospital, Cassidy crafted a bill with Collins that would keep most of the Affordable Care Act’s taxes and allow states to choose between keeping Obamacare largely as is or transition to a new system with more flexibility.
Cassidy has spoken emotionally and in depth about the importance of coverage, saying society pays one way or another when people go to the emergency room because they don’t have insurance, and criticizes the House bill for failing to meet President Trump’s campaign promise of insuring more people at a lower cost.
And then there’s Tom Cotton of Arkansas, normally a staunch conservative, who has emerged as a surprising wild card. He has warned House Republicans to go back to the drawing board because he thinks the bill could endanger the House majority and won’t pass the Senate.
Notably, Arkansas also has an enormous Medicaid expansion population and is one of the poorer states in the union.

State of play

The two toughest votes to get on each side may be Collins and Paul. Paul blitzed the bill even before it was released, when it was being drafted in secret and kept under lock and key, and he has shown repeatedly in the past he’s willing to be the only one in his party to oppose something on principle.
And it’s hard to square the House bill with the rhetoric Collins has used to describe it. She’s noted her state skews old, and the House bill hits older Americans now on Obamacare with premium hikes as high as 759 percent, according to the CBO, to pay for skimpier insurance. She told a local paper last week she couldn’t vote for the House bill as is.
If Paul and Collins both end up voting no, GOP leaders would have to win over everyone else. Leadership hopes could hinge on convincing Cruz and Cassidy to vote for the bill after getting a chance to amend the health bill, even if their amendments ultimately are defeated.
It’s also not clear how much of the House bill will be able to withstand the so-called Byrd rule, which prohibits provisions that aren’t principally budget related. That would potentially require parts of the bill to be rewritten on the Senate side anyway, and then sent back to the House. Final House passage also would be needed if broader amendments pass in the Senate.
Despite the obstacles, Senate Republican leaders say they’re still optimistic they can pass a bill – with Majority Leader Mitch McConnell noting last week that changes could be made during a “vote-a-rama” on amendments. He hopes to pass it before the April recess, bypassing Senate committees and going straight to the floor.
Bloomberg’s James Rowley contributed.

Here’s how Republicans just changed their health care bill

by Lisa Desjardins - PBS - March 22, 2017

Republicans want to repeal parts of the Affordable Care Act and fundamentally redraw health care in America. But first, they need 218 votes in the House by Thursday, when a floor vote is scheduled on the American Healthcare Act. To get them, House GOP leaders filed a package of changes to the bill Monday night. 
The changes come after the Republican leadership was criticized from lawmakers on the left and right for the first version of the bill, which was released earlier this month
So what exactly are they changing?
Big Picture
Overall, the changes take aim at three big areas. 
1) increasing government help to seniors and others paying the most for health care; 
2) eliminating the taxes under President Barack Obama’s Affordable Care Act faster; 
3) giving states more options for Medicaid while further limiting who can sign up for the program. 
To the tax credit, add more tax deduction
What it is: House GOP leaders now want to expand a tax deduction, allowing people to deduct health expenses that amount to more than 5.8 percent of their income.
What it means: Many people expected Republicans to increase tax credits for older Americans. But the tax credits have not changed. Instead, the GOP is expanding a tax deduction. Yes, this is getting complicated — but also interesting. People filing their 2016 taxes already can deduct all health care expenses over 10 percent of their income. The initial GOP bill released two weeks ago would have lowered that threshold to 7.5 percent of income. Now, in the amendment, Republicans propose that deductions start once healthcare spending is over 5.8 percent of income, a policy that would start in 2018. Meanwhile, next year, a special rule would be extended so that seniors could get the expanded deduction right away. 
One note here: In their summary of the proposed changes, House GOP leaders indicated that this tweak may be meant as a pre-emptive peace offering to the Senate, where there is significant concern among Republicans that the bill will simply cost too much for seniors. The expanded tax deduction would cost roughly $85 billion, according to a House aide. The proposed spending boost was a signal that House leaders are willing to put more money on the table, and are open to Senate proposals on other ways to spend the additional funding to help cover seniors’ health care.
ACA taxes go faster
What it is: This new language would end ACA taxes in 2017, a year earlier than the previous GOP bill.
What it means: The first version of the GOP bill did not repeal all ACA taxes until 2018. This latest version proposes repealing them in 2017, meaning they would all be wiped out immediately. This is a decision by Republicans to try to gain support among conservatives, who complained that the first bill was not a fast or broad enough repeal of Obamacare. At the same time, it comes with risks. Add more tax benefits and you’ve added to the pricetag. Now everybody wants to see how (and when) the Congressional Budget Office scores this one.
Medicaid: more power for states, more limits for individuals 
What it is: States would get more power. Fewer people would be automatically eligible for the program.
What it means: The biggest news here might be what Republicans did not change. They did not change the date for freezing the Medicaid expansion program under the ACA. It still closes at the end of 2019. 
But the proposal out Monday does limit the number of people in the program by blocking any of the 19 states which don’t have the expansion now from signing up. 
Most of all, the GOP has added more bells and whistles, in terms of flexibility, to appeal to states. That includes allowing states to choose getting their Medicaid money as a large block grant, rather than as a set amount of spending per recipient. In addition, the changes would let states add a work requirement for non-pregnant adults on Medicaid. 
What we DON’T know
The bill’s shape may have changed, but the same questions remain.What will this mean for individual healthcare costs? How many Americans will be covered under this plan? And what would this do to government costs?

Trump Plan Eliminates a Global Sentinel Against Disease, Experts Warn

by Donald G. McNeil - NYT - March 17, 2017

Nobody in the United States has ever died from an intercontinental missile strike. Over the past 50 years, hundreds of billions of dollars have been spent on silos, submarines, bombers and satellites to ensure that does not happen.
During the same period, nearly 2 million Americans have died from intercontinental virus strikes. The toll includes one American dead of Ebola, 2,000 dead of West Nile virus, 700,000 dead of AIDS, and 1.2 million dead of flu — a virus that returns from abroad each winter.
The federal budget to stop these threats is infinitely smaller than the Pentagon’s, and the Trump administration’s proposed cuts to the National Institutes of Health, and particularly its plan to eliminate the Fogarty International Center at the N.I.H., would, global health experts say, make America vulnerable again.
The Fogarty center, based in Bethesda, Md., was one of the few specific trims in President Trump’s “skinny budget.” It is an odd target: Eliminating it would save only $69 million. The administration did not explain why it was picked, leaving scientists to surmise that it was because the center’s grants pay American doctors to train foreign ones. Mr. Trump has a well-known “America First” bent.
But most of those trainees focus on diseases that circle the globe, researchers point out, including flu, mosquito-borne viruses, vaccine-preventable diseases and bioterrorism agents.
The idea of eliminating the center “is just atrocious,” said Dr. Daniel G. Bausch, a Tulane University virologist and the scientific program director at the American Society of Tropical Medicine and Hygiene. “It would have a severe impact not just on global health but on American health.”
“Even if you don’t care about your neighbors, if you see a fire across the street, your best bet to protect your house is not to just stand in your yard with a bucket of water,” he added. “It’s to help put it out.”
New viral threats are constant. Pathogens like SARS, MERS, dengue and H7N9 avian flu have already probed America’s defenses: Cases have reached these shores in people or in birds, but have not yet killed anyone.
The Zika virus, which is lethal to unborn babies, is still probing our limits; it is expected to return to this country this summer. Still in the wings are a host of other threats: The Nipah virus and Lassa fever, for example, are considered so dangerous that the Bill and Melinda Gates Foundation and other donors recently announced a $500 million fund to jump-start the development of vaccines against them.
Rift Valley fever, Japanese encephalitis, Crimean-Congo hemorrhagic fever and many others lie in wait, and they are less remote than most Americans realize. Crimean-Congo fever, despite its exotic hybrid Russian-African name, circulates even in Spain. It killed someone there last year.
The early-warning system that protects America against viruses resembles the one that protects it against missiles. A network of laboratories around the world, known as World Health Organization reference labs, collects samples from disease outbreaks in local humans, animals and even insects.
Researchers share the genetic sequences, track dangerous mutations, and ship virus samples on to more sophisticated labs that can turn them into vaccines.
Only a tiny number of these sentinel laboratories are in American hands. The Navy runs two in Egypt and Cambodia, for example. And the Centers for Disease Control and Prevention in Atlanta, of course, is one of the apex labs in the W.H.O. reference system, like the top labs in Paris, Moscow and Beijing.
But the system’s furthest-flung sentries — the ones most likely to make first contact with a new viral foe — are those in the world’s poorest countries. These labs are often the descendants of British, French, Dutch or Belgian facilities founded during the colonial era or those started by the Soviets.
Vital as they are to global health, they are usually underfunded and underequipped, and their personnel undertrained. The Fogarty center helps remedy that.
Dr. Bausch has a $50,000 Fogarty grant to plan what could turn into a $2 million to $3 million investment in Sierra Leone, one of the three West African countries where Ebola killed 11,000 people in 2014.
“That would buy lab equipment, train people to run it and to do contact-tracing during an outbreak,” Dr. Bausch said. “The ability to do that is not a given in West Africa. If it had been, we wouldn’t have had that massive Ebola outbreak.”
The skills and equipment donated for one disease often help stop another. For example, early last year, Brazilian ultrasound specialists who had been trained under a Fogarty grant to spot brain abnormalities in Chagas disease victims were among the first to detect early signs of brain deformity in fetuses with Zika.
And Ebola was stopped in Nigeria in 2014 because emergency operations centers and case-detection teams that had been created to find polio victims were drafted to track Ebola cases instead.
Grants by the Pentagon let foreign militaries train with American forces, building alliances. The same is true of Fogarty grants.
When he worked in Pakistan, Bangladesh and Mongolia, said Dr. Sten H. Vermund, an AIDS expert who is now dean of the Yale School of Public Health, “I was able to offer Fogarty-supported training to my overseas partners, and they became the leading lights in H.I.V. when the epidemic hit.”
“Cutting the tiny Fogarty budget is penny-wise and pound-foolish,” he added. “In the old days, we’d float in, get our samples, and leave. We were accused, correctly, of scientific exploitation. Nowadays, you don’t do research abroad if you don’t offer the host country something.”
Once tropical diseases emerge, “they know no borders,” said Dr. Chris Beyrer, former president of the International AIDS Society. “America is not hived off from the rest of the planet, and it’s incredibly important to our biosecurity to have surveillance capability — which means partners in other countries. That’s what Fogarty does.”

Maine Center For Economic Policy - March 21, 2012

Since 2011, Maine has forfeited over $1.9 billion in available federal resources that could have helped protect Mainers’ health and well-being, promote tax fairness, and boost the state’s economy. These funds would have injected up to $700 million into Maine’s economy and supported as many as 4,800 jobs annually.
Download the executive summary (PDF)

Rep. Chellie Pingree: Passing ‘Trumpcare’ would take us backward

The Republicans are fast-tracking a bill that cuts taxes for the rich and raises costs for everyone else.
By Representative Chellie Pingree - Portland Press Herald - March 22, 2017
WASHINGTON — Last weekend, hundreds of Mainers turned out for a town hall I held on the Republican plan to repeal the Affordable Care Act, also known as Trumpcare. People who attended shared their battles with cancer, disease and poverty and described how the Affordable Care Act, while imperfect, had opened a door for them to access care and prevent bankruptcy. 
I’d be the first to say the Affordable Care Act has room for improvement. I was disappointed that we did not accomplish single-payer health care or a public option and that the ACA did not go far enough to hold down costs and keep insurers from unreasonably raising deductibles and out-of-pocket costs. However, nothing in Trumpcare will address rising health care costs. In fact, the Congressional Budget Office said the first draft of Trumpcare will increase out-of-pocket costs for older Americans by as much as 750 percent and immediately drop 14 million people from their coverage. 
Trumpcare not only undoes the gains of the Affordable Care Act, but will actually lead to higher numbers of uninsured than before the ACA was passed in 2010.
Trumpcare is Robin Hood in reverse. It takes health care dollars away from poor, rural, and older Americans in order to give tax breaks to insurance companies, drug companies and the wealthiest Americans. The numbers are simply staggering. Trumpcare will give insurance companies a $145 billion tax break and require individuals who have a gap in their coverage to pay a 30 percent premium surcharge to the insurance company for a year. It will reduce taxes on drug companies by $15 billion and give top earners a $158 billion windfall. 
At the same time, the CBO estimates that a 64-year-old man earning $26,500 a year who previously paid $1,700 for his coverage will pay $14,600 under Trumpcare — that’s more than half his income. Inexplicably, Trumpcare also strips federal funding for Planned Parenthood health centers, which provide basic health care services to thousands of low-income Mainers and millions of Americans nationwide. President Trump recently asked, “Who knew health care could be so complicated?” 
Obviously, he’s never had to navigate the health care system alone and cannot imagine what it’s like to lose his health insurance or have his coverage denied. Most Americans know health care is very complicated. Just take Ed Saxby of South Portland, who attended my town hall on Sunday. 
Ed stood beside his wife, both military veterans, and their granddaughter as he bravely told hundreds of strangers about his battle with cancer. He said that the odds of survival are against him because Trumpcare will take away the tax subsidies he needs to afford health coverage as a retiree living on a fixed income. Ed told the room, “We cannot repeal and not replace — that will be an American genocide.” 
If there were a quick fix to reform our health care system it would have happened 50 years ago, but there’s a reason the Affordable Care Act took two years to pass – we allowed the public to be a part of the process. 
As a member of Congress when the ACA was passed, I remember hundreds of hearings were held and thousands of amendments were considered before President Obama signed the law. 
In stark contrast, Republicans have fast-tracked Trumpcare without holding a single public hearing. Some Republican members will not even face their constituents back home who rightfully want to know how Trumpcare will impact their daily lives.
No one can avoid illness or aging — that’s why health care policy is deeply personal and important to us all. It is unlike any other issue we work on in Congress. 
At my town hall, Ed Saxby’s wife, Jill, asked if those who are championing Trumpcare would be willing to trade places with those who it will harm. It’s a question I’ve posed to my colleagues in Congress and hope they will consider when they vote on Trumpcare on Thursday in the U.S. House of Representatives.

The Republican health care bill will reverse gains made in children’s health

By Claire Berkowitz - Bangor Daily News - March 22, 2017

All Maine children and families should be able to see a doctor when they are hurt or sick. With quality, affordable health insurance, more Mainers can get the care they need to quickly go back to school, work and life.
The health care bill under consideration in Congress, however, moves the country in the opposite direction. If passed, the American Health Care Act would do irreparable damage to the health of our children, families and seniors, leaving states in the lurch during economic or public health crises.
Right now, the Medicaid program is a true partnership between the federal government and the states, but the health care bill caps Medicaid funding and shifts additional costs to the states. This means Maine will receive less money to cover low-income children, seniors and individuals with disabilities, resulting in cuts to coverage, services or provider reimbursement rates.
Too many families are just one bad accident, illness or lost job away from economic ruin. We need to make sure successful programs such as Medicaid — or, as we call it, MaineCare — are there when families need them.
Medicaid is the single largest insurer of children in the country, covering roughly 36.8 million kids, and covering these kids only accounts for about a quarter of Medicaid spending. For children in families who just miss the income eligibility guidelines for Medicaid, they can receive free or low-cost health care coverage through the Children’s Health Insurance Program. Together, these programs ensure that our children can get the preventive care they need so they can play, learn and grow.
In Maine, more than 130,000 children depend on MaineCare for health care coverage. But by radically changing the way Medicaid is funded, the American Health Care Act threatens the health and well-being of nearly half of Maine’s children and their families. It also threatens to reverse two decades of critical gains made in children’s health care coverage.
As of 2016, 95 percent of all U.S. children had health insurance, largely because they can access coverage under Medicaid, the Children’s Health Insurance Program and the Affordable Care Act. When children have access to affordable, health care coverage, they are more likely to receive preventive well-child care, see a doctor when they are sick, miss fewer days of school, and get the services they need at critical developmental junctures. Their parents also miss less time at work and families aren’t threatened by medical bankruptcy. Healthy children are more likely to be on track to become successful adults, which is good for all of us.
If we want this progress to last, we need to protect our children’s care by supporting the programs that cover them and opposing the policies that weaken them. With Children’s Health Insurance Program funding set to expire in the fall, preserving Medicaid funding is more important than ever. But the American Health Care Act would reduce Medicaid spending by $800 billion over 10 years and end Medicaid expansion by 2020, potentially reversing the impressive gains in children’s health care coverage and leaving many children without health insurance.
Changes to the Medicaid program would render Maine unable to care for the children and families in our state the way we do now.
Research shows that parent and child health care coverage is linked, despite differences in eligibility. When parents lose coverage, their children tend to go without coverage, even if they are eligible for coverage through programs such as Medicaid. Children also need healthy parents or guardians to raise them, which is just another reason why quality, affordable health care coverage is so critical.
To put it simply, the American Health Care Act is bad for Maine children and families. Instead of taking health care away from people, we should be investing in those things that help to lift people out of poverty, such as early childhood education and child care, mental health services and job training.
If we want Maine to have a prosperous future, we need our future generation to remain healthy so they can reach their full potential. Protecting the programs that make this happen are critical to our state.
The American Health Care Act puts a target on Maine families — particularly children and seniors — and will undermine the health of our state’s next generation. All of us will pay the price if such a short-sighted and dangerous piece of legislation becomes law.

Claire Berkowitz is the executive director of the Maine Children’s Alliance.


No comments:

Post a Comment