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Saturday, March 25, 2017

Health Care Reform Articles - March 25, 2017

The TrumpRyanCare Debacle

Editorial Board - NYT - March 25, 2017

Repealing the Affordable Care Act was meant to be the first demonstration of the power and effectiveness of a unified Republican government. It has turned out to be a display of incompetence and cruelty.
Republican leaders withdrew the American Health Care Act before a vote scheduled for Friday afternoon after it became clear that they did not have the votes to pass it. Many far-right conservatives opposed the bill because it would not have completely repealed the A.C.A., or Obamacare. And some more moderate Republicans said they would vote no because the bill would cause immense damage — 24 million people would lose health insurance over 10 years and millions of others would be hit with higher premiums and higher out-of-pocket costs. Surely, many of them were also thinking about a recent Quinnipiac University poll showing that 56 percent of American voters opposed the legislation and just 17 percent supported it.
When Barack Obama was president, Republicans in the House voted dozens of times to repeal the health care law in a symbolic exercise meant to appeal to their base. But never did they present a plan that could improve on the law for their constituents. Still, G.O.P. leaders imagined that with the House, Senate and White House in their hands, what had once been a hollow threat could become actual policy. That they failed in this legislative effort could well affect the rest of their agenda — tax cuts for the rich, changing the corporate tax structure and new infrastructure spending. The debacle shows President Trump and Paul Ryan, the speaker of the House, that they can’t count on automatic Republican majorities, especially when they’re offering a destructive, incoherent measure.
Which is pretty much what happened here. Despite their ceaseless attacks on the health care act since Mr. Obama signed it into law in March 2010, Mr. Trump, Mr. Ryan and their colleagues have never had a workable plan that could gain the support of a congressional majority. That is why they rushed their turkey of a bill to the floor without going through the laborious process of holding hearings and building coalitions. The last-minute wheeling and dealing did nothing to disguise the bill’s underlying and increasingly obvious purpose, which was to reduce taxes for the wealthy by cutting benefits for the needy.
Meanwhile, the great dealmaker at the White House was completely ineffectual. Mr. Trump spent a few days cajoling and threatening lawmakers, then threw up his hands and said he had done all he could and was now moving on to other matters. Groups representing doctors and hospitals, as well as public interest groups like AARP and the American Civil Liberties Union, fought hard, and even Republican governors like John Kasich of Ohio and Brian Sandoval of Nevada opposed the bill.
In fact, as Republicans moved closer to a vote, public support for Obamacare went up — 49 percent of those polled this month by the Kaiser Family Foundation had a favorable view of the law, up from 43 percent in December. Obamacare, though not without flaws, has done a world of good. The percentage of Americans who do not have health insurance has fallen to 9.1 percent, from 16.3 percent in 2010. A 2016 Kaiser study of people who gained insurance in California found that 77 percent of them said their health needs were being met very well or somewhat well. By comparison, only 49 percent of those people said their needs were being met three years earlier.
There is no doubt that improvements are needed. Deductibles and premiums are too high for many people, and too many young people are forgoing insurance altogether. More generous subsidies for people with modest incomes could bring the cost of health care down at a relatively small expense to the government.
The worry now among advocates for lower-income Americans and the sick is that the Trump administration might seek to undermine the health care law through administrative steps. For example, officials could seek to reduce subsidies that help people earning just above the federal poverty line pay for out-of-pocket costs. Republicans in the House sued the Obama administration in 2014 to block those subsidies. That case is still pending, and the Trump administration could decide to stop defending the subsidies. Such a move would only compound the mistakes it made by trying to rush a half-baked bill through the House.
Friday’s outcome is good for the country, but humiliating for the Republican leadership. For Mr. Trump, it is a rather brutal reminder that campaigning is the easy part.

Free market is no prescription for our health care woes

Letters to the Editor - Boston Globe - March 25, 2017

Market-based approach misses key component: value of a human life
Jeff Jacoby prefers to replace Obamacare with “a competitive market focused on the interests of consumers,” “price transparency,” and having providers and insurers “compete in earnest” (“Kill Obamacare, and don’t stop at that,” Opinion, March 19). This is reasonable if we are talking about replacing Mom’s 2005 Camry, but it falls apart when we talk about human life. 
To those in favor of market-based solutions for health care, I ask: What is a human life worth in your market? The answer is simple: All human lives are worth the same. Any other reply is repulsive. 
Markets are the land of supply and demand. When there is a blight on the coffee crop, the price goes up and people buy less. Medical care does not conform to the rules of supply and demand, since much of it is governed by what is called inelastic demand, meaning that the percentage change in demand is less than a percentage change in price. My 96-year-old father-in-law had his pacemaker replaced, not because the hospital was running a special, but because not doing so meant the end of his life. 
It is time to take the delivery and funding of health care out of the market.
John May, Franklin

Ever try to ask a health care provider how much a service would cost?

Jeff Jacoby complains that Obamacare is part of a “long saga of health care ‘reforms’that have . . . banished price awareness.” Has he ever tried to find the price of a medical procedure?
I have. Basically, it can’t be done.
Once, they put a paper under my nose asking me to sign off on paying for an MRI if my insurance didn’t. I asked, “Well, how much does it cost?” After 20 minutes of serious, good-faith effort, the final word was that the billing department couldn’t give a price without knowing exactly how the procedure was coded, and the MRI department couldn’t tell me how it would be coded, because this was a kind of MRI in which they don’t decide what to do next until the radiologist has looked at exactly what they see first.
They couldn’t tell me the price of a procedure because, before the procedure, they didn’t know exactly what they would be doing.
And that doesn’t even bring in the questions of how the “consumer” can compare quality.
It is simplistic to suppose competition and comparison apply to health care the same way they apply, say, to buying a dishwasher. The economic model doesn’t fit.
Daniel P. B. Smith, Norwood

We need a system that eliminates a host of wasteful practices

The Globe’s editorial on cost transparency (“Taking the surprise out of your medical bill”) and Jeff Jacoby’s op-ed on eliminating health care subsidies (“Kill Obamacare, and don’t stop at that”) share a misunderstanding of the cost structures in health care. The editorial did not recognize that insurers and health care providers carry out highly secretive and unaccountable deals that make it literally impossible to determine the costs of treating each patient in advance. Jacoby ignored that many sick people can’t earn money and therefore can’t participate in a market for health care. 
The current patchwork of insurance, government programs, and employer-provided coverage actually could work if clinicians eliminated the wasteful practices that Dr. Donald Berwick and others have documented over the decades and learned to work across institutional boundaries to address chronic health conditions.
Andrew Oram, Arlington

Are we going to have health care haves 
and have-nots?

Jeff Jacoby focused only on killing the Affordable Care Act and neglected the essential question: In the greatest country on earth, should health care be a right for all citizens or a privilege only for those with the means to pay?
By advocating the scrapping of subsidies, individual mandates, and coverage for preexisting conditions, he clearly seems to be in the privilege camp. It would have been so refreshing if he had admitted that these changes mean splitting America into health care haves and have-nots, and if he would reiterate how his free-market support would remain steadfast even with a family member of modest means with a disease curable only if they had money for a cure.
Our decades-long free-market approach to health care has produced the world’s highest costs and below-average outcomes. Countries such as the Republic of China and Switzerland recently abandoned free-market health care to cover all their citizens at lower costs. While every approach has its issues, advanced countries have put ideology aside to embrace government-led health care systems that produce better outcomes for all citizens at lower costs. We should do the same.
Robert Banta, Andover

Free-market pipe dream

I wish Jeff Jacoby had pointed out just one example in the world today of a health care system that has brought down prices and increased delivery of quality medical care through the magic of competition in an unregulated free market.
Jim Mesthene, Waltham
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Republicans Land a Punch on Health Care, to Their Own Face

by Jennifer Steinhauer - NYT - March 24, 2017

WASHINGTON — At the end of the long day, the alliance of conservative ideologues who once shut down the government over President Barack Obama’s health care lawcould not find the will to repeal it.
Since the Tea Party wave of 2010 that swept House Republicans into power, a raucous, intransigent and loosely aligned group of lawmakers known as the Freedom Caucus — most from heavily Republican districts — has often landed a punch to its own party’s face.
Friday’s defeat of the Republican leadership’s bill to repeal the Affordable Care Actwas a return to form, handing an immense defeat to President Trump and embarrassing Speaker Paul D. Ryan in his own House. It also challenged the veracity of their long-held claims that a Republican president was all they needed to get big things accomplished.
The most important question for Republicans now is whether the members of the Freedom Caucus will find themselves newly emboldened in ways that may bring the new president more defeats — or whether Mr. Ryan will do what former Speaker John A. Boehner could not, and find a way to shred their influence for good.
“If you are defined by your opposition to leadership, it’s hard to be part of a governing coalition,” said Alex Conant, a onetime aide to Senator Marco Rubio, the Florida Republican who was once a Tea Party star. “Their opposition to Trump’s health care bill should surprise nobody who’s paid attention for the last six years. Even the world’s best negotiator can’t make a deal with someone who never compromises.”
But the Freedom Caucus has never been about compromise. In 2011, it picked a huge, costly fight over Planned Parenthood. In 2013, it orchestrated a government shutdown over funding for the health care law. Then, in its most striking move, it deposed Mr. Boehner in 2015. The common thread: It has continuously been an adversary of legislation itself.
But after years of opposing power — both in the White House, which was occupied by a Democrat, and in the leadership of their own party — the conservatives were offered a chance to negotiate directly with the president and his budget director, a former Freedom Caucus member, over the bill to replace the Affordable Care Act. The members pushed and pushed Mr. Trump to the far right edges of policy, just as they have done for years on other bills. But they still could not get to “yes,” and therefore became part owners of the expansive health law they were trying to undo.
“They made the perfect the enemy of the good,” said Representative Roger Marshall, Republican of Kansas. “I don’t know how they can go back home and tell people they voted to keep Obamacare, voted to keep funding Planned Parenthood.”
Indeed, members of the Freedom Caucus — which is supported by outside conservative groups — have often claimed the mantle of pure conservatism, but their tactics have been seen by many in their party as uniformly counterproductive.
Time after time, they undermined Republican leaders’ efforts to secure wins for the conservative cause by overreaching and demanding the impossible.
They have anointed Representative Mark Meadows of North Carolina as their leader and principal spokesman. But they occasionally get help from three senators sympathetic to their cause: Ted Cruz of Texas, Rand Paul of Kentucky and Mike Lee of Utah.
At critical times, House conservatives have forced their party to make deals with Representative Nancy Pelosi of California, the Democratic leader — an idea anathema to most Republicans, who would seethe.
This time, by negotiating with Mr. Trump on the complex issue of health care, a measure whose complexity he did not seem to fully grasp, they moved an already contentious bill further and further to the right, eliminating too many benefits to keep moderate and other conservative members on board. Even Mr. Trump was said to be taken aback by their attempts to remove things Republicans have long promised to keep, like health insurance benefits for children up to 26 years old.
Given that the House and Senate majorities were built on a promise to repeal and replace Mr. Obama’s signature health care law, many lawmakers fear electoral repercussions. “It is painfully ironic that members from safe, conservative congressional districts who can’t ever quite seem to get to ‘yes’ make it harder to enact good, conservative public policy like repealing Obamacare,” said Michael Steel, a Republican strategist and former aide to Mr. Boehner.
This seemed lost on many Freedom Caucus members on Friday. “Part of the legislative process is working with people who have different ideas,” said Representative Justin Amash, Republican of Michigan. “This process from the beginning wasn’t designed to do that.”
Now, health care has become such a partisan issue that voters seem to have little expectation that their elected officials will do much to solve the problem.
“I believe we should have more attention paid to the centrists in both parties,” said Representative Ileana Ros-Lehtinen, Republican of Florida, one of the early moderate defectors of the bill. “Instead of showing all this attention to three or four people who never vote for anything, let’s do an American health plan, not a Republican or Democrat one.”
Mr. Ryan and Mr. Trump offered up a cheerful patina on what many in Washington viewed as an unmitigated failure, one brought on by a group that had brought down the speaker, shuttered the government and needlessly delayed previous legislation with no significant accomplishments to call its own.
And a new test will come soon as Republicans contemplate an overhaul of the tax code, as the fate of the health care bill throws into doubt whether any major legislation can pass in this climate.
To mitigate this issue, Mr. Ryan will be charged with building the sort of outside coalitions that did not exist for the failed health care bill, which was opposed by doctors, nurses, hospitals, disease groups and conservative political action committees.
“There are lessons from this debate that will be applied to upcoming issues like tax reform, infrastructure and financial reform,” said Ken Spain, who served as the National Republican Congressional Committee’s spokesman in 2010. “Debates are won and lost in the districts and states, not in the cloakrooms of Congress.”
“Winning legislative battles today,” he said, “requires more of an outside-in approach.”

How the Health Care Vote Fell Apart, Step by Step

by Katie Rogers - NYT - March 24, 2017

WASHINGTON — After several days of dramatic back and forth between President Trump and Republicans in Congress, House Republicans pulled a bill to repeal and replace the Affordable Care Act, delivering the president a staggering defeat in his first high-profile legislative effort.
That’s quite a turn of events. Let’s break them down.

What happened?

Republican leaders shelved the legislation on Friday afternoon — shortly before an expected vote — after House members spent days pushing for concessions on the replacement proposal, called the American Health Care Act. A day before, after the vote was postponed, Mr. Trump demanded that a vote be held on Friday. But the bill was pulled as it looked as though it would fall shy of the 215 votes needed to pass the House.
Who decided to pull the bill? Mr. Trump and the House speaker, Paul D. Ryan, both said it was their decision.
“Ryan says that he advised Trump to pull the bill,” Julie Hirschfeld Davis, a White House correspondent for The New York Times, wrote in a live analysis. “Interesting, because Trump told us that he had directed Ryan to yank it. A lot of blame-shifting going on.”

How did the vote get derailed?

The proposal would have replaced the Affordable Care Act, known as Obamacare, with a system of age-based tax credits to purchase insurance coverage, and its provisions brought a divide between ultraconservative and moderate House Republicans into relief.
This is the gist: The most conservative members of the House didn’t think that the American Health Care Act would go far enough to eradicate Obamacare, and moderates were concerned about an estimate by the nonpartisan Congressional Budget Office that 24 million Americans would be left without insurance.
Republican leaders bent to the will of the House Freedom Caucus, a group of about 30 hard-line members, agreeing to remove several federal mandates for minimum benefits, including mental health services and some maternity care. But this move still didn’t go far enough to appease members of the caucus. And the concessions alienated several moderates.

How has President Trump reacted?

By blaming the Democrats.
In a phone call to The New York Times on Friday, Mr. Trump noted that no Democrats had pledged to support the bill, and that they would probably seek a deal once “Obamacare explodes” because of rising premiums and declining options. Speaking later to reporters in the Oval Office, he criticized Nancy Pelosi, the House minority leader, and Chuck Schumer, the top Senate Democrat.
“Now they own Obamacare,” he said. “They own it.”
Mr. Schumer fired back on Twitter.

Mr. Trump praised Mr. Ryan for working “very, very hard.” He summed up this exercise in legislative failure as a “very interesting experience.”
But this bill was the first major test of Mr. Trump’s ability to corral members of Congress to fulfill his campaign promises, and it was a stunning failure. A president who has prided himself on his negotiation skills in the business world learned the limits of his sway in his new office.

What happens next?

The Affordable Care Act stays intact.
“We’re going to be living with Obamacare for the foreseeable future,” Mr. Ryan told reporters on Friday.
The president seemed to agree. “It’s enough already,” said Mr. Trump, who has been president for just over two months. The Republicans will be moving on to tax reform, which Mr. Ryan said would be an uphill battle.
In the meantime, Democrats are rejoicing. For now.

How did we get here?

For at least the past year and a half, Mr. Trump had talked about quickly repealing and replacing the current health care law. It was a signature campaign promise.
Shortly after taking office, Mr. Trump shifted course, warning that it might take until 2018 to make sure it was done correctly.
But in this White House, a lot can change in a month, and Republicans unveiled the first version of their plan four weeks later. What followed was a series of quick changes to try to appease conservative and moderate House Republicans.
On Thursday, Mr. Trump sent a message to Republicans: Either vote to replace the Affordable Care Act, or leave it in place.
Clearly, that ultimatum backfired.

In a Call to The Times, Trump Blames Democrats for the Failure of the Health Bill

by Maggie Haberman - NYT - March 24, 2017

WASHINGTON — Just moments after the Republican plan to repeal and replace the Affordable Care Act was declared dead, President Trump sought to paint the defeat of his first legislative effort as an early-term blip.
The House speaker, Paul D. Ryan, was preparing to tell the public that the health care bill was being withdrawn — a byproduct, Mr. Trump said, of Democratic partisanship. The president predicted that Democrats would return to him to make a deal in roughly a year.
“Look, we got no Democratic votes. We got none, zero,” Mr. Trump said in a telephone interview he initiated with The New York Times.
“The good news is they now own health care. They now own Obamacare.”
Mr. Trump insisted that the Affordable Care Act would collapse in the next year, which would then force Democrats to come to the bargaining table for a new bill.
“The best thing that can happen is that we let the Democrats, that we let Obamacare continue, they’ll have increases from 50 to 100 percent,” he said. “And when it explodes, they’ll come to me to make a deal. And I’m open to that.”
Although enrollment in the Affordable Care Act declined slightly in the past year, there is no sign that it is collapsing. Its expansion of Medicaid continues to grow.
In a later phone interview with The Times, the Senate minority leader, Chuck Schumer, ridiculed Mr. Trump’s remarks about Democrats being at fault.
“Whenever the president gets in trouble, he points fingers of blame,” Mr. Schumer said. “It’s about time he stopped doing that and started to lead. The Republicans were totally committed to repeal from the get-go, never talked to us once. But now that they realize that repeal can’t work, if they back off repeal, of course we’ll work with them to make it even better.”
Mr. Trump said that “when they come to make a deal,” he would be open and receptive. He singled out the Tuesday Group moderates for praise, calling them “terrific,” an implicit jab at the House Freedom Caucus, which his aides had expressed frustration with during negotiations.
Even so, he tried to minimize the deep divisions within his own party that prevented Mr. Ryan from securing passage of the bill, and maintained that they were six to 12 votes away from getting it across the finish line.
As Mr. Trump spoke, his voice was flatly calm and slightly hoarse, his manner subdued. He talked on a speaker phone from his desk in the Oval Office, with a coterie of aides drifting by. At one point, he welcomed his daughter Ivanka back from a ski trip.
Mr. Trump said that in states he had visited in the last two weeks, Tennessee and Kentucky, the problems with President Barack Obama’s signature legislation were evident. The president said he was now moving on to taxes and trade as priorities.
Mr. Trump described his first major legislative experience as not terribly different than what his previous negotiations as a real-estate developer had been like.
He emphatically did not fault Mr. Ryan.
“I don’t blame him for a thing, I really don’t,” Mr. Trump said. He added: “Even during the midst of negotiations I said the best thing that could happen was just to back off. I said, I’ll do it now because I’m a team player.” He said that Mr. Ryan did not apologize to him, adding: “Look, he tried. He tried very hard.”
“I’m not disappointed,” he insisted. “If I were, I wouldn’t be calling you.”

In Dropping Health Vote, Trump Swallowed Need for a Showdown

by Julie Hirschfeld Davis and Maggie Haberman - NYT - March 24, 2017

WASHINGTON — When Speaker Paul D. Ryan arrived at the White House on Friday to inform President Trump that the health care bill he had made his first major legislative push could not pass, Mr. Trump had one reaction: He wanted revenge.
Furious at rebellious Republicans who refused to back the measure, Mr. Trump demanded that defectors cast “no” votes for all to see — even if it meant the measure’s high-profile defeat, broadcast live on television.
But over a lunch of chicken, brussels sprouts and twice-baked potatoes in the Oval Office, Mr. Ryan pleaded with Mr. Trump to reconsider.
A loss could do lasting political damage to Republicans who supported the contentious bill, Mr. Ryan argued, especially those in competitive districts who were vulnerable to primary challenges. It would do nothing to isolate or punish the Freedom Caucus, the conservative faction that had resisted the measure all along, he added.
And it could alienate rank-and-file Republicans needed to push through other challenging initiatives in the weeks to come, including an increase in the debt ceiling, a sweeping tax cut and the president’s promised $1 trillion infrastructure package.
Mr. Trump remained unconvinced, but by midafternoon, armed with vote counts showing that the measure lacked a majority to pass, the president called the speaker to agree: You should pull the bill.
The collapse of the measure dealt Mr. Trump — a professed master dealmaker who campaigned as an agent of change — a remarkable setback in his young presidency, threatening to sap his influence and imperil his ambitious agenda. It also highlighted the importance of a pairing that will shape the Trump era: a president inexperienced in the complexities of politics and uninterested in the nuance of policy, paired with a vulnerable speaker struggling to corral competing coalitions within the Republican Party.
With repeal and replace now a hollow vow, Mr. Trump’s anger at the defiant members of the Freedom Caucus was undiminished. But trying to put the best possible face on a major defeat late Friday afternoon, he confined his public criticism to Democrats.
“When you get zero from the other side — they let us down because they’re hurting the people,” Mr. Trump said in a telephone interview shortly after he had agreed to pull the measure. Asked whether he was worried the loss would hurt Republicans, he said, “I’ll let you know in a year.”
The demise of the American Health Care Act played out in a tense 24 hours that White House and congressional officials said proved a political education for Mr. Trump and his top advisers on the promise and peril of governing, even with unified Republican control. This account is based on government officials who were present during the last-minute negotiations and who spoke on the condition of anonymity.
“We all learned a lot,” Mr. Trump told reporters on Friday afternoon. “We learned a lot about loyalty, and we learned a lot about the vote-getting process.”
“Certainly for me, it was a very interesting experience,” he added.
Mr. Trump, who initially had little involvement in crafting the health care bill, became more deeply engaged in recent weeks, promoting it at rallies outside Washington and holding meetings in the West Wing with conservative and moderate coalitions whose support was crucial to its passage.
But he made little secret of his ambivalence about addressing the issue — “I would have loved to have put it first, I’ll be honest,” Mr. Trump said of tax reform in Nashville last week — yet he told aides he believed the measure could not pass without a push from him.
By Thursday afternoon, just hours before a scheduled vote, it had become clear that his efforts — along with those of Vice President Mike Pence and other senior White House officials — had fallen short. At a meeting in Mr. Ryan’s office in the Capitol with members of the recalcitrant Freedom Caucus, top White House officials laid out the changes they had made at the group’s behest, including stripping it of federal standards for benefits that must be provided in health insurance policies, including maternity and wellness care.
Caucus members began outlining still more changes they needed to see before they could support the bill, angering Mr. Ryan and Mr. Trump’s aides. Stephen K. Bannon, the president’s chief strategist, and Mick Mulvaney, his budget director, told the group that the White House was finished negotiating and that the president wanted to know its position on the bill — yes or no.
Called on in turn to state their positions, several members refused. As tensions rose, Representative Mark Meadows of North Carolina said that he spoke for the group and that they were not ready to commit. That meant the votes would not be there.
Mr. Ryan postponed the vote and called an evening meeting of House Republicans in the basement of the Capitol. Lawmakers munched on Chick-fil-A takeout as Mr. Mulvaney delivered the president’s ultimatum on the health measure: Fall in line behind it or accept that former President Barack Obama’s Affordable Care Act would be the law of the land. The speaker emerged and told reporters there would be a vote in the morning, rushing away from the news cameras as he was asked if Republicans had the votes.
In a 45-minute telephone call Thursday evening between Mr. Trump and Mr. Ryan, the two commiserated over the demands of the caucus and strategized over the prospects for a vote on Friday.
Even as the two spoke, some of Mr. Trump’s advisers were privately expressing frustration with Mr. Ryan, arguing that he had badly misjudged the situation and misled the president into tackling health care before a tax overhaul.
The meeting with the Freedom Caucus had prompted a realization by Mr. Trump and his inner circle about how the group operated, and that offering it policy concessions would not win its support.
By Friday, Mr. Trump was out for blood, eager to call the bluff of the Freedom Caucus and savage it if the health bill went down in defeat. Mr. Bannon and Marc Short, Mr. Trump’s legislative affairs director, both favored holding the vote.
But Mr. Ryan, reluctant to suffer an embarrassing loss or to ask his fellow Republicans to take what could be a politically perilous vote on a measure that had little chance of passing, argued vigorously against it.
White House officials still believed as much as half of the 40-member Freedom Caucus could be pressured into supporting the bill, and Mr. Bannon demanded to see a confidential vote-count list that demonstrated otherwise. The numbers were grim, and Mr. Trump called Mr. Ryan to acquiesce into calling off the vote.
“I don’t blame him for a thing, I really don’t,” Mr. Trump said of Mr. Ryan in the interview on Friday. “Look, he tried. He tried very hard.”
But one close adviser said that Mr. Trump, who hates looking weak or any form of embarrassment in public, was stewing.
One ally of the president, however, said that he had learned from the process. Christopher Ruddy, the chief executive of Newsmax Media and a longtime friend of Mr. Trump, said he thought it was a “blessing in disguise” that the bill had died.
“This bill was a political bullet aimed at the president and congressional Republicans running for office next year,” he said. “On future legislation, he won’t make the same mistakes.”
As Mr. Trump reflected on the health care debacle, the president who had predicted during the campaign that he would win so often that people would become “sick of winning” insisted that he was at peace with the day’s results.
“I’m not disappointed,” he said in the interview. “If I were, I wouldn’t be calling you.”
He said that he was moving on to overhauling the tax system and trade, describing the experience with the health bill as not that different from some of his negotiations as a real-estate developer.
But he acknowledged that he was pleased to have it all behind him.
“It’s enough already,” he said.



The TrumpRyanCare Debacle

by The Editorial Board - NYT - March 25, 2017

Repealing the Affordable Care Act was meant to be the first demonstration of the power and effectiveness of a unified Republican government. It has turned out to be a display of incompetence and cruelty.
Republican leaders withdrew the American Health Care Act before a vote scheduled for Friday afternoon after it became clear that they did not have the votes to pass it. Many far-right conservatives opposed the bill because it would not have completely repealed the A.C.A., or Obamacare. And some more moderate Republicans said they would vote no because the bill would cause immense damage — 24 million people would lose health insurance over 10 years and millions of others would be hit with higher premiums and higher out-of-pocket costs. Surely, many of them were also thinking about a recent Quinnipiac University poll showing that 56 percent of American voters opposed the legislation and just 17 percent supported it.
When Barack Obama was president, Republicans in the House voted dozens of times to repeal the health care law in a symbolic exercise meant to appeal to their base. But never did they present a plan that could improve on the law for their constituents. Still, G.O.P. leaders imagined that with the House, Senate and White House in their hands, what had once been a hollow threat could become actual policy. That they failed in this legislative effort could well affect the rest of their agenda — tax cuts for the rich, changing the corporate tax structure and new infrastructure spending. The debacle shows President Trump and Paul Ryan, the speaker of the House, that they can’t count on automatic Republican majorities, especially when they’re offering a destructive, incoherent measure.
Which is pretty much what happened here. Despite their ceaseless attacks on the health care act since Mr. Obama signed it into law in March 2010, Mr. Trump, Mr. Ryan and their colleagues have never had a workable plan that could gain the support of a congressional majority. That is why they rushed their turkey of a bill to the floor without going through the laborious process of holding hearings and building coalitions. The last-minute wheeling and dealing did nothing to disguise the bill’s underlying and increasingly obvious purpose, which was to reduce taxes for the wealthy by cutting benefits for the needy.
Meanwhile, the great dealmaker at the White House was completely ineffectual. Mr. Trump spent a few days cajoling and threatening lawmakers, then threw up his hands and said he had done all he could and was now moving on to other matters. Groups representing doctors and hospitals, as well as public interest groups like AARP and the American Civil Liberties Union, fought hard, and even Republican governors like John Kasich of Ohio and Brian Sandoval of Nevada opposed the bill.
In fact, as Republicans moved closer to a vote, public support for Obamacare went up — 49 percent of those polled this month by the Kaiser Family Foundation had a favorable view of the law, up from 43 percent in December. Obamacare, though not without flaws, has done a world of good. The percentage of Americans who do not have health insurance has fallen to 9.1 percent, from 16.3 percent in 2010. A 2016 Kaiser study of people who gained insurance in California found that 77 percent of them said their health needs were being met very well or somewhat well. By comparison, only 49 percent of those people said their needs were being met three years earlier.
There is no doubt that improvements are needed. Deductibles and premiums are too high for many people, and too many young people are forgoing insurance altogether. More generous subsidies for people with modest incomes could bring the cost of health care down at a relatively small expense to the government.
The worry now among advocates for lower-income Americans and the sick is that the Trump administration might seek to undermine the health care law through administrative steps. For example, officials could seek to reduce subsidies that help people earning just above the federal poverty line pay for out-of-pocket costs. Republicans in the House sued the Obama administration in 2014 to block those subsidies. That case is still pending, and the Trump administration could decide to stop defending the subsidies. Such a move would only compound the mistakes it made by trying to rush a half-baked bill through the House.
Friday’s outcome is good for the country, but humiliating for the Republican leadership. For Mr. Trump, it is a rather brutal reminder that campaigning is the easy part.

The Republicans’ Health Care Defeat

Letters to the Editor - NYT - March 24, 2017

To the Editor:
The Republican-led House of Representatives just presented President Trump and Speaker Paul Ryan with a stunning political defeat by failing to support the bill to repeal the Affordable Care Act (nytimes.com, March 24).
Is this what Mr. Trump calls the “Art of the Deal”? Perhaps his vaunted negotiating skills do not translate well into the political arena. In any event it was a totally self-inflicted wound. Why?
First, it was a mistake to start his legislative agenda with health care “reform.” He should have started with tax and regulatory reform, much less contentious and much easier to pass.
Second, it was self-inflicted because the Republican Party leaders (at least Mr. Ryan) took their own campaign rhetoric too literally. They had been beating the drum for repeal and replace Obamacare for so long they actually believed it was what the people wanted (the majority do not).
They could have chosen to just repeal it now, with an effective repeal date in one year. Then they could have tried to work on a bipartisan bill with more real popular support and passed it next year.
Mr. Trump, right about now I’m guessing you really wish you had the absolute power of Vladimir Putin to effect change; you do not. There are real limits to your power, as we have just seen amply demonstrated.
KEN DEROW, SWARTHMORE, PA.
To the Editor:
Former President Barack Obama enjoys vindication as a colossal embarrassment has been sustained by President Trump and House Republicans, both forced to share blame for the collapse of their much-heralded American Health Care Act.
Mr. Trump exerted brute force in an effort to secure votes for the plan, and he got nowhere. Republican House members recognized that their primary allegiance is not to their president, but to the constituents before whom they will appear on the ballot next year. Conservatives found the bill to be too generous, while moderates concluded that it was cruel.
Changes should be made to the Affordable Care Act to make it sustainable. If the Republicans want to make those changes, they will have to eat crow, and work with Democrats who will insist on maintaining the framework of the Obama legislation.
Could this stunning defeat cause President Trump to finally demonstrate some humility?
OREN M. SPIEGLER
UPPER ST. CLAIR, PA.
To the Editor:
After seven years of unrelenting contempt for President Obama and the Affordable Care Act, and with seven years to come up with an alternative, the Republicans, now that they have control of Congress and the White House, just showcased their incompetence.
The only surprise would be if, after this fiasco, they were willing to work with Democrats to actually improve the Affordable Care Act. I’m not holding my breath.
CHARLES MERRILL, NEW YORK
To the Editor:
Republicans have never liked the idea of a national health care system. President Obama’s triumph in passing the Affordable Care Act infuriated them into an obsession to make it fail by any means necessary, lying about its successes and convincing their base that it was a terrible system.
Now the Republicans are facing a crisis of their own making, when a bipartisan effort could have made the Affordable Care Act work for everyone at reasonable costs.
Of course, it would be so much easier (and less expensive) to expand Medicare to cover all Americans — but that would make Republicans’ heads explode, so it’s off the table.
CAROL ROBINSON, NEW YORK


The Democrats’ Next Move on Health Care

by Andrew Sprung - NYT - March 24, 2017

The American Health Care Act, Paul Ryan’s Obamacare repeal bill, seems to be on thin ice after Mr. Ryan pulled it from a House floor vote on Friday for lack of votes. But the priorities and passions that gave it shape are still very much alive and at work within Republican ranks.
The bill landed with a thud when first released on March 6. Within 48 hours, groups representing hospitals, doctors, nurses, nursing homes and the elderly announced their opposition. Moderate Republican senators called for changes to soften the likely coverage losses, particularly those caused by rollback of the Medicaid expansion. Freedom Caucus zealots (and their right-wing think tank backers) complained that it wasn’t harsh enough.
Democrats can’t assume that the impasse will last. Republicans have pushed themselves through seven years of denunciation and dozens of (vetoed) repeal votes to destroy the Affordable Care Act “root and branch.” It’s possible that a revised version of the bill will someday squeak through the House and even pass the Senate.
The Freedom Caucus’s absolutist demands have obscured a more fundamental point on which it and the Republican leadership agree: downsizing and hollowing out Medicaid. Andy Slavitt, former acting administrator for the Centers for Medicare and Medicaid Services, warned in a tweet before the Ryan bill came out: “Don’t get distracted by exchanges. The big issue is dramatic cuts in Medicaid to pay for huge tax cuts.”
Staring into the abyss of Republican intentions that produced this bill, a Democrat might daydream: What if there were a Republican bill that did not repeal the A.C.A.’s revenue sources, did not repeal the Medicaid expansion and left states free to maintain the current marketplace structure?
In fact, there is such a bill. It was introduced in January by four Republican senators: Bill Cassidy of Louisiana, Susan Collins of Maine, Shelley Moore Capito of West Virginia and Johnny Isakson of Georgia. It’s called the Patient Freedom Act (known informally as Cassidy-Collins), and it was almost entirely ignored by Republican leadership.

The bill is cast as a federalist compromise. It is flawed, but it could provide the basis for a deal between Democrats and Republicans.
In Cassidy-Collins, states can choose between the existing A.C.A. marketplace structure (at 95 percent of current funding) and an alternative structure, centered on government-funded health savings accounts, to be used in a deregulated market where catastrophic plans feature prominently. Access to the subsidy pot would be extended to include higher-income individuals, weakening subsidies for lower-income people. In states that chose this option, the A.C.A.’s Essential Health Benefits — required features of any plan — would be repealed, as would the individual and employer mandates. States could also use the funded health savings accounts option to replace the Medicaid expansion.
States have two other options: They can choose to reject federal funding entirely and give up on the whole A.C.A. project or seek “innovation waivers” to devise their own federally funded program.
Senate Democrats should engage with the Cassidy-Collins sponsors and other Republican senators who have expressed qualms about the Ryan proposal. Many of those senators are in states that embraced the A.C.A. Medicaid expansion, collectively slashing the ranks of their uninsured by 45 percent.
But they generally call for delaying Medicaid’s phaseout, not stopping it. Even the Republican governors in states that embraced the A.C.A.’s Medicaid expansion, posing as champions of its beneficiaries, floated an alternative plan that left expansion states with a Catch-22: either accept per capita caps on the federal Medicaid contribution, or give up enhanced federal funding for the expansion’s beneficiaries. Left to their own devices, the Senate moderates are likely to prove equally limp champions of the expansion, or of the federal commitment to making health insurance affordable for all Americans.
This is why it’s urgent for Democrats to act now. If a quorum of three or more of this demurring dozen is to block these destructive changes — and defy the president — they need an alternative path. Democrats can provide it by working with Senators Cassidy and Collins, and others who wish to devote Obamacare-level resources to extending coverage.
Of course they will have to overcome some natural aversion. Allowing states to junk the A.C.A.’s coverage rules, channel subsidies through health savings accounts (which generally work only for people with significant resources), distribute a reduced subsidy pot to wealthier individuals or opt out of subsidizing coverage may strike many as a poison pill.
But Republican governors and legislatures that wish to do these things can do them right now, with the exception of opting out of subsidizing coverage entirely. The A.C.A. allows states to seek innovation waivers from the Department of Health and Human Services to remake their marketplaces, proposing alternatives to the law’s coverage rules, subsidy formulas and employer and individual mandates. The state must show that the alternative scheme will cover as many people as Obamacare would, as comprehensively and at comparable cost. With Tom Price as the secretary of Health and Human Services, conservative state governments could doubtless win approval for any plan they proposed.
Cassidy-Collins makes a show of pitting rival ideological models against each other — but it also preserves the A.C.A.’s waiver provision. To improve the bill, Democrats could soften that binary choice and open the innovation waiver channel wider, loosening H.H.S. oversight. Health care scholars on the left and right have suggested that such a “superwaiver” compromise is the only way to end the parties’ ideological war over health insurance access.
Ultimately, both sides need a deal. The A.C.A. has endured relentless Republican defamation and outright sabotage — most notably defunding of a crucial risk-adjustment program. No benefit program can withstand perpetual assault from one of our two major parties. On the other hand, no party in its right mind takes steps to uninsure tens of millions of constituents.
If the Ryan plan founders, the individual insurance market may very well collapse in the uncertainty. The Trump administration has already taken several measures certain to depress enrollment. While a nuclear blame war will inevitably ensue, the administration and Congress will be forced to take steps to shore up the market.
At that point, perhaps both sides will stagger toward a health care truce — driven in part by the president’s craving to validate his core brand as a deal maker. And there will be Cassidy-Collins, pointing the way toward a superwaiver solution: federal funding for states to take and try to make health insurance affordable for all their residents, by what means they will.

With Epic GOP Failure, Dems Urged to Go Bold with Medicare-for-All

Americans rallied against the GOP to defend their right to healthcare, Democrats are being urged to seize on the moment
by Lauren McCauley - Common Dreams - March 24, 2017
With the Republican attempt to replace the Affordable Care Act (ACA) going down in flames Friday as Americans rallied to defend their right to healthcare, Democrats are being urged, both by experts and constituents, to seize on the moment and counter with a plan that will truly provide coverage for all.
Uproar over the GOP's American Health Care Act (AHCA), which was estimated to strip 24 million people of their healthcare by 2026, prompted a political firestorm as it drove voters across the nation to town halls and local legislative offices to demand that House Republicans vote against the bill.
After the White House called on House Speaker Paul Ryan (Wis.) to withdraw Friday's scheduled vote (after an aggressive lobby effort on the part of both President Donald Trump and Ryan), many are looking to what happens next.
Though the Republican narrative that Obamacare is "imploding" has been proven to be an unfounded talking pointThe Week's Ryan Cooper argued Friday that Democrats "shouldn't sit idly by and wait for Republicans to slowly bleed Obamacare to death by other means."
"They need a counter-offer," Cooper writes, "one that's more compelling than the creaky status quo. They need a single-payer, Medicare-for-All plan."
Similarly, RoseAnn DeMoro, executive director of National Nurses United (NNU), told Common Dreams that ultimately Democrats "are fighting for an unacceptable status quo," noting that a private insurance market will always prove to be "unaffordable."
In a press statement she expanded on this idea:
Many of the criticisms of the ACA are, in fact valid. For all the improvements under the ACA, primarily the expansion of Medicaid and crackdown on some insurance abuses, the ACA still left 28 million without health coverage, and millions more struggling with un-payable medical bills and escalating out of pocket costs.   
Where the Democrats too fell short was their failure in drafting the ACA to refute the underlying source of the health care crisis in the first place, the contradiction between a health care system that should be based on patient need and the public health and well being, and the insatiable demand of health care corporations for profits first.
Dr. Carol Paris, president of Physicians for National Health Program (PNHP), which has long-advocated for single-payer system, said Friday's failure by the Republican Party to pass their "slash and burn" healthcare bill "presents a unique opportunity to move beyond" a profit-based system.
Though Paris acknowledged the GOP plan would have "pushed millions more Americans off their health insurance, sending the rates of medical bankruptcy and preventable deaths skyrocketing," she said the shortcomings of the ACA should not be ignored.
"The ACA left 29 million Americans uninsured and channeled billions of taxpayer dollars to a patchwork of wasteful private insurers, each one skimming off its own share of administrative costs and profit that should have been spent on patient care," Dr. Paris noted. "Let's clear the drawing board—it's time to adopt a simple, commonsense approach to national health care."
Pointing to the collapse of the GOP's attempt at reform, DeMoro says it's clear their party has no viable pathway towards a solution. "The Republicans are ideologically split it appears," she said. "Trump is trying to maintain that everyone should have healthcare and the cost should go down—that solution, and the only possible solution is Medicare-for-All."
In a Friday press statement, Rep. Luis  GutiĆ©rrez (D-IL) echoed this call. "We have known for years that the only true healthcare reform that will work is a single-payer system where we take national responsibility for the health of our nation," he said. "Now that this vote is over, I hope we can return to a serious and sensible discussion of strengthening our healthcare system and the improving the health of all Americans."
In addition to Medicare-for-All being "quite clearly the best universal health-care policy option for the United States," The Week's Cooper also observed that "Obamacare did not finish the job of achieving universal health care, and this is a good chance to move the ball forward."
The AHCA, Cooper continues, "is extraordinarily unpopular because it takes coverage and subsidies away from people, and a majority believe that it should be the government's responsibility to make sure everyone is covered. Fundamentally, Medicare is very popular, a fact only partially covered up by generations of red-baiting and duplicitous austerian propaganda."
Further, he notes that "it also makes an excellent organizing signpost. Medicare-for-All is simple, easy to understand, and hard to argue against or distort."
The math works out too. Dr. David Himmelstein and Dr. Steffie Woolhandler, both of whom are closely associated with PNHP, published an analysis this week which found that replacing the ACA "with a universal, single-payer health system, along the lines of the Expanded and Improved Medicare for All Act, H.R. 676, would provide immediate coverage to the 26 million Americans who are currently uninsured, saving at least 20,984 lives in year one."
This is in contrast to the Congressional Budget Office estimate that as many as 24 million people would lose health coverage by 2026 under the AHCA.
Responding to Friday's developments, Sen. Bernie Sanders (I-Vt.) called the failure of the AHCA a "great victory," but said that lawmakers' work would not be complete until healthcare was guaranteed "to all people as a right":
Contrary to Republican orthodoxy, many of Trump's blue collar supporters voted for him specifically because he promised to "take care of everybody." Speaking with some of those voters in West Virginia recently, Sandersfound that many do believe that healthcare should be guaranteed as a human right.
Sanders, who made Medicare-for-All a key plank of his 2016 presidential campaign, said recently that the president's supporters "are catching on that Trump lied."
Robert Frank, an economics professor at the Johnson Graduate School of Management at Cornell University, argued in a New York Times op-ed Friday that the president could preserve the floundering effort to replace Obamacare while making good on his campaign promises by getting behind a Medicare-for-All, or single payer, healthcare plan.
Trump should use his "political leverage...to jettison the traditional Republican approach in favor of a form of the single-payer health care that most other countries use."
Taking to social media after the cancelled House vote on Friday, U.S. voters showed there's a real hunger for such a solution:http://www.commondreams.org/news/2017/03/24/epic-gop-failure-dems-urged-go-bold-medicare-all

Saving Obamacare Is Not Enough—We Need Medicare for All

The terms of the health-care debate must be shifted.
by Dennis Kucinich - Common Dreams - March 24, 2017

The health-care debate in America is essentially an argument over what kind of private insurance market people should have access to: President Obama’s, where the insurance companies made out like bandits, or President Trump’s, where insurance companies will make out like bandits.
Let’s change the debate by making it between for-profit insurance vs. not-for-profithealth care. That’s what I and Congressmen John Conyers and Jim McDermott sought to do in 2003 when we wrote and introduced Medicare for All, HR 676, in the House of Representatives.
Six years ago, I was the last Democrat hold-out on “Obamacare.” My constituents desperately needed coverage for pre-existing conditions and for their adult children. I reluctantly voted for it to prove that some reform was possible, not because it was an acceptable end-point.
It still left out millions and left consumers at the mercy of insurance companies. And everyone knows insurance companies make money by providing as little health care as possible.
Here is what the for-profit insurance system brings:
  • Rising premiums and co-pays.
  • Diminishing coverage.
  • More government subsidy of private insurers.
  • Rising costs for prescription drugs.
  • More people going bankrupt because of hospital bills.
  • More people losing their homes because of hospital bills.
More seniors forced into poverty, losing everything they worked for their entire lives.
This is not about Democrats vs. Republicans, liberals vs. conservatives, left vs. right. This is about life vs. death.
This is about whether we, as Americans, can recognize a common interest in using the vast resources of our nation to insure the health of our people.
Heath spending approaches nearly 18 percent of the $20 trillion GDP. Nearly a trillion dollars of that amount goes for corporate profits, stock options, executive salaries, advertising, marketing, and the cost of paperwork.
If we took all the money that people and the government are presently paying into the for-profit system and applied it to care for people in a not-for-profit system, we could provide for basic health care for all Americans, including prescription drugs, vision care, dental care, mental-health care, and long-term care.
That is what HR 676, Medicare for All, was all about.
Medicare for All is an idea whose time has come. Let’s make all Americans healthy and wealthy. Let’s lift up all of our families, save our homes, and help our businesses and industries. Let’s join every other industrialized nation in the world and offer health care to all of our people.
The terms of the debate in Washington must be shifted. We must not be stuck between competing for-profit health-insurance schemes. Let’s renew the debate: Medicare for All or profit for a few.



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