Browsing the archives for the Health Care category.


Trump’s Wrecking Company

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Health Care, Trump Maladministration

For a brief, shiny moment it seemed the Senate would save the cost-sharing subsidies and the ACA. Yesterday  Sens. Lamar Alexander and Patty Murray submitted a bill that was supposed to do that, anyway.

Yesterday, Trump appeared to approve of this plan. Today, he does not. He still thinks it’s a “bailout” of the insurance industry. Sarah Kliff explains:

Trump has said he will discontinue the second [cost sharing] subsidy program. But insurance companies are still required by law to provide these subsidies to their low-income enrollees. They cannot jack up the deductibles on someone who earns 200 percent of the poverty line, even though the government has stopped providing the money.

Insurance companies don’t want to lose money. They need a way to offset the sudden loss of billions in government funds. So, they looked for other levers to pull. And many settled on raising premiums as a way to recoup those lost funds.

Paul Waldman wrote today:

President Trump is facing a dilemma: Does he want to destroy the American health-care system or not? At this point, all evidence suggests that he genuinely can’t decide what the answer to that question is. …

… When the Alexander-Murray agreement was announced yesterday, Trump at first seemed supportive. “It is a short-term solution, so that we don’t have this very dangerous little period — including dangerous periods for insurance companies,” he said at a press conference. “For a period of one year, two years, we will have a very good solution.” But then this morning, he tweeted, “I am supportive of Lamar as a person & also of the process, but I can never support bailing out ins co’s who have made a fortune w/ O’Care.”

What gives? When you try to interpret the president’s shifting positions — and figure out how this is all going to end — there are a few things you have to keep in mind. First, it’s wise to assume that he has no idea how any provision of this agreement or the ACA itself actually works, and that will not change. For instance, he seems to have convinced himself that cost-sharing reductions are like an extra bonus given to insurance companies that they’ll just use to pad their profits. “That money is going to insurance companies to lift up their stock price,” he has said, when in fact the money is basically passed through the insurers to provide lower co-payments and deductibles for people with low incomes. He hasn’t bothered to learn what the law does, and he certainly isn’t going to quickly get up to speed on new proposals to provide technical fixes.

Still, it might be that if he were presented with a bill to sign, he’d sign it. However, Paul Ryan probably has more enthusiasm for cold oatmeal than he has shown for this bill.

“The speaker does not see anything that changes his view that the Senate should keep its focus on repeal and replace of Obamacare,” a Ryan spokesperson told Axios.

So, not much chance anything is going to happen. Jonathan Swan and David Nather write at Axios that nobody has any idea what Trump actually thinks, “But it’s fair to say that everyone who is remotely conservative inside the administration is pushing not to keep funding the Affordable Care Act’s insurer subsidies without serious concessions.”

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You Won’t Get It If You Don’t Ask for It

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Democratic Party, Health Care

Hubert Humphrey at the 1948 Democratic National Convention

Hubert Humphrey’s Civil Rights speech at the 1948 Democratic National Convention was one of the great moments in the party’s history.

“Friends, delegates, I do not believe that there can be any compromise on the guarantees of the civil rights which we have mentioned in the minority report,” he said. “In spite of my desire for unanimous agreement on the entire platform, in spite of my desire to see everybody here in honest and unanimous agreement, there are some matters which I think must be stated clearly and without qualification. There can be no hedging — the newspaper headlines are wrong. There will be no hedging, and there will be no watering down — if you please — of the instruments and the principles of the civil-rights program.”

Humphrey was speaking in support of the civil rights plank of the 1948 Democratic Party platform, which said this:

The Democratic Party is responsible for the great civil rights gains made in recent years in eliminating unfair and illegal discrimination based on race, creed or color,

The Democratic Party commits itself to continuing its efforts to eradicate all racial, religious and economic discrimination.

We again state our belief that racial and religious minorities must have the right to live, the right to work, the right to vote, the full and equal protection of the laws, on a basis of equality with all citizens as guaranteed by the Constitution.

We highly commend President Harry S. Truman for his courageous stand on the issue of civil rights.

We call upon the Congress to support our President in guaranteeing these basic and fundamental American Principles: (1) the right of full and equal political participation; (2) the right to equal opportunity of employment; (3) the right of security of person; (4) and the right of equal treatment in the service and defense of our nation.

This platform also said “We favor legislation assuring that the workers of our nation receive equal pay for equal work, regardless of sex,” and called for some kind of national health care. Seriously, this is a very progressive platform, the domestic policy section especially. The Dems would have to update the foreign policy section, but the domestic policy section could be adopted in 2020 with just a little tweaking.

Did I mention this was said in 1948?

Of course, there were many years of struggle ahead before the Civil Rights Act of 1964 made discrimination illegal. Martin Luther King and the Civil Rights movement forced the Democratic Party to introduce that law,  and we’re still struggling to fully implement that law.  My point is that before change could happen, somebody had to stand up and say this. Somebody had to commit to this. Somebody had to say, this is the right thing to do.

I’m sure Hubert Humphrey didn’t expect racial discrimination to disappear after the election. As it was, the entire Mississippi delegation and half of the Alabama delegation stomped out of the convention in protest of the civil rights plank. Two weeks after the convention, President Truman issued executive orders mandating equal opportunity in the armed forces and in the federal civil service. Southern segregationists  organized to form a “states’ rights” party and nominated Strom Thurmond as its presidential candidate.  Civil rights was a divisive issue for Dems in 1948. But they adopted that platform because it was the right thing to do.

Today, we’re squabbling over an issue that shouldn’t be that divisive — universal health coverage. Whether you call it “single payer” or “Medicare for All” or just “universal coverage,” by now it should be obvious to anyone with a functional brain that achieving this is going to require some sort of national, taxpayer-supported system that sidelines for-profit insurance companies and includes controls to prevent price gouging. It’s almost certainly going to mean phasing out job-based group insurance. Beyond that, the hundreds of other nations that provide universal coverage for its citizens have gone about this in various ways, not all of them “single payer,” strictly speaking. We should be studying them.

The hysterical reaction against the Affordable Care Act never made sense, if you realize that just about all the ACA did was regulate health insurance to force insurance companies to cover more people and provide some subsidies so that poor people could pay the private insurance company premiums. That the premiums were still not affordable for a lot of folks is largely the fault of the insurance companies, and indeed it’s the fault of the whole idea that private-for profit insurance can pay for most medical care with affordable premiums and without bankrupting people. It can’t. All the other nations of the world figured that out a long time ago.

But in the U.S., the insurance companies, the medical-industrial complex and the conservative media-think tank network that largely controls public opinion have made universal coverage a taboo subject. Until now.

There are 16 Democratic senators supporting the bill, a remarkable number considering where the healthcare debate was two years ago, when Sanders first campaigned for president as a democratic socialist long shot. At the time, pundits, political operatives and countless elected officials dismissed the single-payer Sanders dream as a disingenuous moonshot.

Now, the man who told Obama to lay off Bain Capital (Cory Booker) and the woman who once voted in favor of withholding federal funds from sanctuary cities (Kirsten Gillibrand) are co-sponsors of Sanders’ bill. Times, indeed, have changed.

Some are not persuaded.

In an interview with Vox’s Ezra Klein, Clinton repeated attacks on single-payer she made during her primary campaign against Sanders, arguing that more modest measures like a public insurance option or a Medicare buy-in for people 55 and older are more realistic and achievable.

“I don’t know what the particulars are” on Sanders’s latest plan, Clinton said, but added, “He introduced a single-payer bill every year he was in Congress — and when somebody finally read it, he couldn’t explain it and couldn’t really tell people how much it was gonna cost.”

She clarified that she’d support a bill opening up Medicare or Medicaid and cutting prescription drug costs, but cautioned, “I think it’s going to be challenging if within that bill, there are tax increases equivalent to what it would take to pay for single-payer, and if you’re really telling people — about half of the country — that they can no longer have the policies they have through their employer.”

She noted that this issue arose in 1993-’94, when she was crafting a health reform plan in the Bill Clinton administration, and she concluded then that the forces arrayed against single-payer, not least of which were the public’s fears about such a program, were insurmountable.

Those forces may have been insurmountable in 1993-1994; there are people who argue that the Clintons themselves blew the opportunity then, but let’s set that aside. I personally think it was insurmountable in 2008; just getting the ACA passed was a massive achievement at the time.

But it’s not 1994 any more. It’s not even 2008 any more.

I’ve long believed that universal health care would become politically viable in the U.S. as soon as a big enough part of the working and middle class in the U.S. realized that they are being screwed by the medical-industrial complex, and I think we’re about there.

When Mike Dukakis talked about health care reform in his presidential bid in 1988, all the Republicans had to do was trot out some hard hat guys with union benefits to talk about the great health coverage they had for a few dollars a month, and why mess with that? But those hard hat guys are harder to find these days.

In  1999, 67 percent of nonelderly Americans were covered by employee insurance. In 2014, that had fallen to 56 percent, as the old-fashioned full-time job with benefits became more and more  elusive in the U.S.  If we include all Americans, less than half are covered by employee benefit insurance now. See also “Let Them See How We Live. Let Them Come.”

People in the U.S. don’t know what solutions are possible because nobody tells them. Sanders’s cardinal sin, according to some, is that he stood up and told people what is possible. Apparently, according to some Democrats, this is not allowed. We are not allowed to speak the name of a thing until we have a fully formed program with all the details ironed out, and even then we must limit ourselves to those programs that are achievable in the near term, under current political conditions. This means Democrats negotiate with themselves until they come up with something that they think Republicans might accept, so that it can be watered down some more before passing.

Under those rules, Hubert Humphrey wouldn’t have been allowed to speak at the 1948 Democratic Convention, and the civil rights plank would have been axed from the platform. Yes, the 2016 Democratic platform has a section about “securing universal health care,” but the verbiage that follows is about protecting the status quo —

Democrats will keep costs down by making premiums more affordable, reducing out-of-pocket expenses, and capping prescription drug costs. And we will fight against insurers trying to impose excessive premium increases.

— and maybe throwing in a few tweaks to existing programs, but it offers nothing that looks anything like genuine universal coverage.

Paul Waldman wrote last week,

Support for some kind of universal coverage is now the consensus position among Democrats. And Sanders’ single payer plan is the one that has gotten the most attention, so it’s going to be the one against which other plans are measured.

But we have to understand this plan for what it really is: an opening bid. While he won’t say so himself, I doubt even Sanders believes that something in this form could pass through Congress. Even so, it represents an important strategic shift for the Democratic Party.

Waldman goes on to say that both Barack Obama and Bill Clinton tended to negotiate with themselves, giving away too much too quickly before negotiations with Republicans even started. On the other hand, Sanders’s Medicare for All asks for everything. It covers everything, without co-pays or deductibles. It even covers abortions. And, as a lot of people have pointed out, such a bill has no chance of passage in Washington now. But a watered-down bill has no chance, either.

Waldman continues,

This bill is being offered in 2017, when there’s a Republican president, a Republican House, and a Republican Senate. It doesn’t have to be realistic. It can be a way of saying, “This is what as Democrats we think a perfect health insurance system would look like.” In that sense, this bill could be extremely useful, since it will communicate the Democratic vision to voters in a way that isn’t too hard to understand. …

… Once the Sanders plan is in wide circulation, if I said, “How about an expansion of Medicaid to become a basic plan for all adults, while private insurance would still exist to offer supplemental coverage?”, you might now say that sounds pretty reasonable. If you did, it would mean that Sanders had effectively widened the debate and made what not long ago would have seemed like radical ideas look like moderate compromises.

Exactly. It tells people what is possible. It’s saying, we can have this, or something like this, if we demand it. We don’t have to put up with the status quo.

To me, one of the biggest mistakes Hillary Clinton made last year was not just to dismiss Sanders’s health care plan as politically untenable, but to compare even asking for universal coverage — which is what most people mean by “single payer” — to believing in unicorns. The widely circulated video of her proclaiming that single payer will “never ever come to pass” damaged her more than she seems willing to admit.

Josh Marshall wrote last week,

Medicare for All is a horizonal demand. It satisfies a basic need and does so by looking beyond the corrupt, meretricious system we now have. The activity of private insurance companies symbolize much that is wrong with contemporary capitalism. You don’t have to be a leftwinger from Park Slope to hate these companies. Believe me: a lot of those people who voted for Trump (whom the liberal elite dismisses as racists and misogynists) hate insurance companies.

While Medicare for All would cause an upheaval in the health insurance markets, it is actually based on expanding a system that works and that has remained intact for over fifty years. It’s incremental in its own way. It is also very easy to understand, while most of the incremental reforms I’ve seen require a degree in healthcare economics to comprehend and rarely seem to apply to “you.”

Unfortunately, a lot of Democrats are still too mired in learned helplessness to stand up for what’s right; see Democrats Against Single Payer by Branko Marcetic at Jacobin. So it’s going to be up to voters to continue to apply pressure on the Democrats to grow a spine. Watch them fold up like cheap lawn chairs as soon as Republicans begin their pushback. Socialized medicine! Higher taxes! Booga booga booga booga!

I say, let the Republicans go to their constituents and tell them no, you can’t have this. We must support the medical-industrial complex. We must support the rights of insurance companies to make lots of money, even if you or your loved ones are cut off from life-saving medical care for the sake of profit. Let the Republicans defend that position. Stop being afraid to stand up for the right thing.

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The Creature Lives

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Health Care, Trump Maladministration

See Tierney Sneed at Talking Points Memo and Dylan Scott at Vox to make sense of what went on in the Senate today.

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Trump’s Got No Mojo on Health Care

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Health Care, Trump Maladministration

I’ve had some kind of stomach bug for the last few hours, but have decided I will survive. So, back to work.

So today the so-called President said this:

President Trump promised a surprise on the matter, though he did not specify what.

“Health care is working along very well. . . . We’re going to have a big surprise,” Trump told reporters at the White House on Wednesday. “We have a great health-care package.”

Trump offered no details, only reiterating, “We’re going to have a great, great surprise.”

I’m going with “delusional,” myself. The New York Times reported this:

If Republicans do manage to broker a deal — as Senator Mitch McConnell of Kentucky, the majority leader, pledged to do during a lively East Room back-and-forth with the president — it is not likely to be because of Mr. Trump’s involvement. Until Tuesday afternoon, the president was largely on the sidelines as the fate of one of his most important campaign pledges played out.

Mr. McConnell, who kept the president at a polite arm’s length while he oversaw negotiations over the bill, asked Mr. Trump to arrange the meeting with all 52 Republican senators during a morning phone call, in part to show senators the White House was in fact fully engaged, according to two people with knowledge of the call.

When asked by reporters clustered on the blacktop outside the West Wing if Mr. Trump had command of the details of the negotiations, Mr. McConnell ignored the question and smiled blandly.

WaPo is more scathing:

The president is the leader of his party, yet Trump has struggled to get Republican lawmakers moving in lockstep on health care and other major issues, leaving no signature legislation in his first five months in office. The confirmation of Supreme Court Justice Neil M. Gorsuch is his most-cited achievement to date.History suggests that presidents who have governed successfully have been both revered and feared. But Republican fixtures in Washington are beginning to conclude that Trump may be neither, despite his mix of bravado, threats and efforts to schmooze with GOP lawmakers. …

… The Senate could pass a revised version of the bill once lawmakers return from their July 4 recess and pick up deliberations. Still, some Republicans are willing to defy their president’s wishes — a dynamic that can be attributed in part to Trump’s singular status as a disrupter within his party.

“The president remains an entity in and of itself, not a part of the traditional Republican Party,” said Rep. Carlos Curbelo (R-Fla.), a moderate who represents a district Trump lost by 16 percentage points. “I handle the Trump administration the same way I handled the Obama administration. When I agree, I work with them. When I oppose, I don’t.”

The man’s got no political capital at all.

One senior Republican close to both the White House and many senators called Trump and his political operation “a paper tiger,” noting how many GOP lawmakers feel free “to go their own way.”

And, I suspect, they will.

In private conversations on Capitol Hill, Trump is often not taken seriously. Some Republican lawmakers consider some of his promises — such as making Mexico pay for a new border wall — fantastical. They are exhausted and at times exasperated by his hopscotching from one subject to the next, chronicled in his pithy and provocative tweets. They are quick to point out how little command he demonstrates of policy. And they have come to regard some of his threats as empty, concluding that crossing the president poses little danger.

“The House health-care vote shows he does have juice, particularly with people on the right,” Sen. Lindsey O. Graham (R-S.C.) said. “The Senate health-care vote shows that people feel that health care is a defining issue and that it’d be pretty hard for any politician to push a senator into taking a vote that’s going to have consequences for the rest of their life.”

Asked if he personally fears Trump, Graham chuckled before saying, “No.”

And so on. Do read the whole thing. See also The GOP’s health-care bill is political kryptonite and The dirty little secret of the GOP’s health care push: Not even Republicans are demanding this.

Mitch McConnell is pushing for a revised bill to be voted on this Friday, before the Senate goes into recess. I’m predicting he will fail. Surprise!

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Stuff to Read, TrumpCare Edition

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Health Care, Trump Maladministration

I’m short on time today and can only provide some links to keep you busy —

Charles Pierce, Paul Ryan Doesn’t Know How Insurance Works

LA Times, The GOP isn’t replacing all of Obamacare — just the parts that work

Jonathan Chait, Watch Paul Ryan’s Adam’s Apple When He’s Asked Why His Health Plan Cuts Taxes for the Rich

Greg Sargent, Trump has a secret backup plan to kill Obamacare. It’s actually brilliant.

Gail Collins, Getting Freedom from Health

Josh Marshall, Why Repeal and Replace Are Going So Badly

If you run into any more good ones, please add them to the comments.

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Don’t Read This Without a Helmet

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Health Care, Trump Maladministration

Helmet on? Okay, this happened today:

President Donald Trump told a bipartisan group of governors at a White House reception Monday morning that GOP tax reform would have to wait for lawmakers to move on repealing Obamacare, cautioning that, “Nobody knew that health care could be so complicated.”

“I have to tell you, it’s an unbelievably complex subject,” Trump said.

I’ll pause to let you pound your head on the desk for a while.

I take it somebody attempted to explain to Trump why Republicans just couldn’t kill the mandate but leave the pre-existing condition coverage.

This also tells me he is just now finding out what the issues are with health care. I’m sure he assumed anybody could write a health care bill that gave everybody what they wanted. What was the big deal?

Right now, the Republicans seem to be dividing between the kill-Obamacare-and-let-the-chips-fall crowd and those who suspect that suddenly depriving millions of people of health care might hurt their re-election chances.

And it has to be said that Trump pre-screwed the pooch for them by promising that no one currently covered would lose coverage. Republicans can come up with all kinds of great plans as long as people don’t actually have to be covered. The coverage thing, though, is an impossible hurdle. Jonathan Chait wrote,

Health-care reform is extremely complicated even under the best of circumstances. But when you combine the inherent complexities of the subject with the ideological rigidities of the conservative movement, the problem goes from hard to prohibitively impossible. Providing access to medical care to the tens of millions of Americans who can’t afford it on their own, because they’re too poor or too sick, is arithmetically futile if you’re bound by a dogma that opposes redistribution from the rich and healthy to the poor and sick.

But we know what’s really important, don’t we?

House Republicans have decided to resolve the contradiction between party dogma and the promise not to harm the public in favor of the former. A study prepared by the National Governors Association, and which leaked to the media Saturday evening, finds that the House Republicans leadership’s formative plan to replace Obamacare will deprive millions of people of their insurance.

Repealing Obamacare is more important to these people than finding ways to deliver health care to the American people. Many would prefer to repeal the law and blow up the health care system than to dedicate even one tax dollar to helping a poor person see a doctor. They have principles, you know.

But Trump promised better and less expensive coverage. Back when he was still pretending to be developing a plan himself, he promised this. This is from January 15:

President-elect Donald Trump said in a weekend interview that he is nearing completion of a plan to replace President Obama’s signature health-care law with the goal of “insurance for everybody,” while also vowing to force drug companies to negotiate directly with the government on prices in Medicare and Medicaid. …

…Trump’s declaration that his replacement plan is ready comes after many Republicans — moderates and conservatives — expressed anxiety last week about the party’s lack of a formal proposal as they held votes on repealing the law. Once his plan is made public, Trump said, he is confident that it could get enough votes to pass in both chambers. He declined to discuss how he would court wary Democrats….

…As he has developed a replacement package, Trump said he has paid attention to critics who say that repealing Obamacare would put coverage at risk for more than 20 million Americans covered under the law’s insurance exchanges and Medicaid expansion.

“We’re going to have insurance for everybody,” Trump said. “There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.” People covered under the law “can expect to have great health care. It will be in a much simplified form. Much less expensive and much better.”

Republican leaders have said that they will not strand people who gained insurance under the ACA without coverage. But it remains unclear from either Trump’s comments in the interview or recent remarks by GOP leaders on Capitol Hill how they intend to accomplish that.

For conservative Republicans dubious about his pledge to ensure coverage for millions, Trump pointed to several interviews he gave during the campaign in which he promised to “not have people dying on the street.”

“It’s not going to be their plan,” he said of people covered under the current law. “It’ll be another plan. But they’ll be beautifully covered. I don’t want single-payer. What I do want is to be able to take care of people,” he said Saturday.

Here’s a television news story from about the same time. So we’ve got him both in print and in video.


ABC Breaking News | Latest News Videos

Very smart people who have been wrestling with the health care issue for a long time understand that cost-effective, universal coverage can’t be done without going to a taxpayer-funded national health care system that includes price controls of all sorts. Short of that, there’s Obamacare or something like it, mandate and all.

But Trump promised everybody rainbows and ponies. People could get terrific, affordable coverage, and Republicans could nix the mandate and cut taxes. Everybody wins. Back to Jonathan Chait:

Trump held together the contradiction by simply pretending the solution would reveal itself over time and would be extremely easy. Quite likely Trump believed this himself — as a committed nonreader, and a narcissistic devotee of his own negotiating prowess, he surely believed that he could broker a deal that would satisfy both the moral objective of universal coverage and the specific ideological hang-ups that had prevented his party from ever supporting a plan that would accomplish it in the past.

The only thing that held Trump’s position together was a refusal to engage with the substance of the issue, and a magical belief that it could all be waved away. At best, he will keep either his promise to the Republican elite or his promise to the electorate. At worst he will keep neither. His offhand comment that the issue is hard is a window into the mind of a man who realizes the jig is almost up.

Maybe. Maybe he thinks that if he throws bigger tantrums someone will come up with the solution for him. I predict that eventually he will cave on his promise to voters and will blame them for it.

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Trump: Everybody Gets a Pony! But Maybe Not Health Insurance

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Bad Hair, Health Care, Medicare, Republican Party

By now you’ve probably heard that Trump is putting the finishing touches on a health care plan that will provide health insurance for everybody.

President-elect Donald Trump said in a weekend interview that he is nearing completion of a plan to replace President Obama’s signature health-care law with the goal of “insurance for everybody,” while also vowing to force drug companies to negotiate directly with the government on prices in Medicare and Medicaid. …

… Trump said his plan for replacing most aspects of Obama’s health-care law is all but finished. Although he was coy about its details — “lower numbers, much lower deductibles” — he said he is ready to unveil it alongside Ryan and Senate Majority Leader Mitch McConnell (R-Ky.).

“It’s very much formulated down to the final strokes. We haven’t put it in quite yet but we’re going to be doing it soon,” Trump said. He noted that he is waiting for his nominee for secretary of health and human services, Rep. Tom Price (R-Ga.), to be confirmed. That decision rests with the Senate Finance Committee, which hasn’t scheduled a hearing.

Since he mentioned Tom Price here, one suspects that if there is an actual Trump plan, it’s Tom Price’s. So let’s look at that. Here is what Price has proposed:

1. Get rid of the insurance exchanges and their subsidies. Instead, offer fixed tax credits to help people buy insurance on the private market.

Those tax credits would be fairly modest, ranging from $1,200 a year for people 18 to 35 years of age to $3,000 for those 51 and older. In many regions of the country, that would hardly begin to cover the premiums and out-of-pocket costs for a relatively comprehensive health insurance plan.

2. Insurance companies cannot deny insurance to people with pre-existing conditions provided they been insured continuously for the previous 18 months. If you lose coverage because you can’t make a payment, too bad. No insurance for you.

3. “Expanded” health savings accounts. HSAs are great for young, healthy people who need tax shelters; not so much for anybody else.

4. There would be taxpayer funded high-risk pools for sick people who can’t get insurance. These have been tried in the past and have proved to be bottomless money pits. I’m sure the insurance companies like this idea, though, because it lets them off the hook for insuring really sick people.

Price appears to be seriously low-balling the scope of the problem by proposing to invest a mere $3 billion into state risk pools over a three-year period. Ryan’s “Better Way” plan, for instance, would provide $25 billion over the coming decade, and even that might prove to be woefully inadequate.

5. Price wants to limit the employer tax exclusion for providing health insurance to $8,000 a year for individual policies and $20,000 for families. I suspect people would see their employee benefit health insurance taking bigger bites out of their paychecks.

6. Able-bodied single people would no longer be eligible for Medicaid, no matter how poor they are.

7. Price wants to allow insurance companies to sell insurance across state lines. Republicans are in love with this idea because they think that the competition would force insurance premiums to go down. Nobody who understands the health insurance industry thinks this would work.  See also articles in The Fiscal Times, Forbes, and the New York Times explaining why this is a dumb idea.

What Trump probably will propose is a system that would in theory allow anybody to get insurance, but in practice probably would leave out most or all of the people who gained insurance under the ACA, and more beside. Paul Ryan and other Republicans like to make speeches about giving people “universal access” to health insurance, instead of universal insurance coverage, which I interpret to mean “you can buy all the insurance you want, as long as you can pay for it.” Which, of course, is the catch.

But Trump specifically said,

“We’re going to have insurance for everybody,” Trump told the Washington Post. “There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.”

He’s either lying or he doesn’t know what he’s talking about. Of course, both might be true. You either stick with some version of the ACA, or go with a single payer/national health care plan, or throw people into the private insurance market to sink or swim. There really aren’t any other options. Tom Price’s ideas won’t work to make health insurance affordable or  reduce health care costs. Health care costs are the real cause of high premiums, and health care costs are high in the U.S. because we have a for-profit system that allows for rampant price gouging.

The part about allowing Medicare to negotiate drug prices is something Republicans have fought tooth and nail since Part D was established in 2003. (Medicaid already allows for some negotiation.) President Obama tried to tweak the Medicare system a bit to allow for some negotiation, but Republicans balked at that, too. Part D is a cash cow for the pharmaceutical industry, and those lobbyists aren’t going down without a fight. Trump will be in for a fight from his own party on that one.

(I have to crab about Democrats, too, however. Recently Bernie Sanders introduced an amendment that would have allowed importation of cheaper drugs from other countries. This had enough Republican votes it would have passed, except that a gang of Democrats voted against it.)

 

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Are Wheels Coming Off the ACA Repeal Bus?

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Bad Hair, Health Care

There are signs congressional Republicans are beginning to get a clue that repealing Obamacare without a good plug and play replacement already in hand might come back to bite them. Jonathan Chait writes,

Something big is happening in the Senate right now: The Republican plan, affirmed again today by Senate Majority Leader Mitch McConnell, is facing dire peril from Republican defections. Republicans need a House majority, 50 Senate votes, and soon-to-be President Trump to pass repeal and delay.

If Republicans lose three Senate votes, that drops them to 49, and repeal and delay cannot pass. At least three Republican senators (in addition to all the Democrats) now oppose repeal and delay. Rand Paul, of all people, has demanded that Congress repeal Obamacare at the same time it passes a plan to replace it. Paul has announced that he spoke with Trump and secured his agreement on this. Trump has not said so himself, confining his comments to date to a vague assurance, “That’s all gonna work out.”

Trump, of course, tends to change his mind frequently and agree with whomever he spoke with last. But other Republicans senators are taking the initiative. Fellow Republican Lamar Alexander says the same thing as Paul: “We have to take each part of it and consider what it would take to create a new and better alternative and then begin to create that alternative and once it’s available to the American people, then we can finally repeal Obamacare.” Senator Tom Cotton of Arkansas said on MSNBC, “It would not be the right path for us to repeal Obamacare without laying out a path forward.” And Senator Bob Corker is walking right up to the edge of the same position, asking Trump to tweet out confirmation of what Paul claims he promised. “If it is his view, it would be really good if he would consider tweeting it out very clearly. There’s more and more concerns about not doing it simultaneously,” Corker says.

Over in the House, Paul Ryan is pushing a bill that would use budget reconciliation to kill significant parts of the ACA. But on top of the three senators who oppose “repeal and delay,” four more Republican senators — Portman, Collins, Cassidy, and Murkowski — joined Corker in sponsoring a bill that would delay Ryan’s Obamacare repeal for a month. They say they just want to be sure everyone is clear about what comes next before they go forward with repeal.

(And since when do we ask presidents to “tweet out” what their intentions are?)

Conservatives hate Obamacare because it redistributes too much money from the rich and healthy to the poor and sick. But they don’t publicly attack the law on that basis. Instead they attack it for high premiums, high deductibles, and narrow choice of doctors and hospitals — all flaws that any Republican plan would have in much higher doses. Republicans have yet to unify around a single, concrete, scorable plan because it is conceptually impossible to design a health-care plan that meets conservative ideological goals and is also acceptable to the broader public.

Ryan is talking about making repeal and replace “concurrent” —

“It is our goal to bring it all together concurrently,” said Ryan. “We already show people what we believe in, what we believe Obamacare should be replaced with. so we’re going to use every tool at our disposal — through legislation, through regulation — to bring replace concurrent along with repeal so we can save people from this mess.”

Hmm. Well, what they believe in is that people without money should just die already. But we really haven’t seen what they think Obamacare should be replaced with. They make noises about various things — high-risk pools, tort “reform,” selling policies across state lines — that don’t add up to a comprehensive whole. There is no way they’re going to fund high-risk pools enough to make them work. That’s a symbolic fix only. Their other ideas barely rise to the level of “tweaks.”

But then there’s this:

On Monday night at Tortilla Coast, a Mexican restaurant on the Hill, the House Freedom Caucus – a group of fiscal conservatives with a reputation for rabble rousing–came to a consensus that they wanted more insight into what the GOP’s replacement is before they vote on a budget resolution slated to be taken up Friday in the House.

 If the House Freedom Caucus is getting nervous about repeal, this is serious. I would have expected them to push for repeal, period, and don’t worry about the replace. But I guess some of them want to be re-elected.

A reconciliation bill requites only a simple majority to pass the Senate, but you can do only so much with a reconciliation bill — change taxes and spending, and that’s about it. Actually changing the system requires a regular bill, which would require some Democratic votes.

The idea behind “repeal and delay” was that by setting a deadline for a replacement, Democrats might be pressured into writing the bill. Republicans, as you know, are congenitally incapable of crafting legislation without help from ALEC. But if there’s no delay, there’s no pressure.

And then there’s the Trump factor. Greg Sargent wrote this morning,

When Trump holds his news conference tomorrow, he will likely be asked whether he still thinks that Republicans should repeal and replace the Affordable Care Act “simultaneously,” as he said in a post-election interview. If he answers in the affirmative, it could throw the current GOP strategy — repeal on a delayed schedule with no guarantee of any replacement later — into further doubt.

 So, we’ll see.

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Hey, Republicans: Put Up or Shut Up

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Bad Hair, Health Care, Republican Party

Martin Longman sums it up:

The Republicans have had tremendous success with what they know best, which is being a very good minority party. They can counter-message and use procedural tools in obnoxiously innovative ways to obstruct. They can simply refuse to even hold hearings for presidential nominees or insist that those positions don’t even need to be filled. They excel at this stuff, but they do not excel at legislating or doing oversight of the federal government and its agencies.

Their plan here is the plan of a minority party. They want to force the Democrats to do something rather than figuring out a way to do it themselves. They have no idea how to replace Obamacare without blowing up the private insurance industry, costing hundreds of thousands of people their health insurance, and taking all the political blame. So, they’ll just try brinksmanship and maybe those clever law-writing Democrats will rescue them at the end of the day out of some bleeding heart do-gooder sense of decency.

So far, the Democrats appear to be happy to let the the Republicans twist in the wind.

Schumer is taking a hard line when it comes to Republican plans to repeal the law, and whether or not Democrats would work across the aisle on a replacement if Republicans are successful in rolling it back. “And if they think we’re going to come in and save their butts when they screw it up? No.”

Schumer also proposed “Make America Sick Again” as a new Republican motto.

The Trumpster issued a new tweetstorm in the wee hours in which, among other things, he called Chuckie Schumer the “head clown.” This was followed by a call for Republicans and Democrats “to get together and come up with a healthcare plan that really works – much less expensive & FAR BETTER!” Yeah, that’ll work.

Schumer fired back today.

“Now, we understand that President-elect Trump is in a difficult spot, that Republicans are in a difficult spot. They want to repeal ACA, and have no idea how to replace it,” he said. “But instead of calling names, [the] President-elect should roll up his sleeves and show us a replacement plan that will cover the 20 million Americans who gained coverage, that will cover students or post-college students, 21 to 26, who want to stay on their parents’ plan, that will show how we cover people with pre-existing conditions.”

“So I’d say to the President-elect and the Republicans that this is not a time for calling names. It’s time for them to step up to the plate if they want to repeal, and show us what they’d replace it with,” Schumer added.

Also, too, yesterday dear Bernie Sanders brought an oversized print of one of the Donald’s old tweets and put it on display in Congress.


Sanders said Trump should either admit he was lying or say he will veto any forthcoming cuts.

“Millions of people voted for him on the belief that he would keep his word,” he said. “If he was sincere, then I would hope that tomorrow or maybe today he could send out a tweet and tell his Republican colleagues to stop wasting their time and all of our time. And for Mr. Trump to tell the American people that he will veto any proposal that cuts Medicare, that cuts Medicaid or that cuts Social Security.”

And when Trump made those promises on the campaign trail, I suspect his followers assumed he knew how he would make it happen. But it’s obvious he doesn’t have a clue.

See this article by Drew Altman in today’s New York Times — “The Health Care Plan Trump Voters Really Want.”

Surveys show that most enrollees in the Affordable Care Act marketplaces are happy with their plans. The Trump voters in our focus groups were representative of people who had not fared as well. Several described their frustration with being forced to change plans annually to keep premiums down, losing their doctors in the process. But asked about policies found in several Republican plans to replace the Affordable Care Act — including a tax credit to help defray the cost of premiums, a tax-preferred savings account and a large deductible typical of catastrophic coverage — several of these Trump voters recoiled, calling such proposals “not insurance at all.”

And it isn’t insurance at all.

One of those plans has been proposed by Representative Tom Price, Mr. Trump’s nominee to be secretary of Health and Human Services. These voters said they did not understand health savings accounts and displayed skepticism about the concept.

When told Mr. Trump might embrace a plan that included these elements, and particularly very high deductibles, they expressed disbelief. They were also worried about what they called “chaos” if there was a gap between repealing and replacing Obamacare. But most did not think that, as one participant put it, “a smart businessman like Trump would let that happen.”

However, they also said this:

They were unmoved by the principle of risk-sharing, and trusted that Mr. Trump would find a way to protect people with pre-existing medical conditions without a mandate, which most viewed as “un-American.”

I don’t find the need for the mandate that hard to grasp, and I’m not exactly brilliant when it comes to number things.

But it does seem to me that if these people get their insurance ripped out from under them, with nothing to replace it but some blah blah health savings account blah, even they may notice they’ve been had.

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Republicans Scramble for a Plan. And a Clue.

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Bad Hair, Health Care, Obama Administration, Republican Party

The original plan to kill Obamacare was “repeal and delay,” meaning Congress would pass a repeal bill that wouldn’t go into effect for at least a couple of years, thereby putting pressure on Democrats to help come up with a replacement. But that appears to be abandoned.

According to this article by Peter Sullivan at The Hill, the new plan is to go ahead and repeal Obamacare — there will be a repeal bill on Trump’s desk by February 20, they say — and then Trump will magically make all the rough transitional thingies go away by executive orders.

Seriously, that’s the plan.

The Feb. 20 target was put forward by incoming House Budget Committee Chairman Diane Black (R-Tenn.), said Rep. Markwayne Mullin (R-Okla.), leaving a meeting with House Republicans and Vice President-elect Mike Pence on Wednesday.

Pence said Trump plans to take executive actions to start unwinding ObamaCare on day one, but did not get into specifics.

“It will be an orderly transition to something better … using executive authority to ensure it’s an orderly transition,” Pence told reporters. “We’re working now on a series of executive orders that will enable that orderly transition to take place even as Congress appropriately debates alternatives to and replacements for ObamaCare.”

Rep. Chris Collins (R-N.Y.), an early Trump supporter, added that, “The president in his first day in office is going to do some level of executive orders related to ObamaCare.”

But Collins said there were “no details whatsoever” on the orders discussed in the meeting.

They have no idea what they’re going to do. They’re about to hit the Put Up or Shut Up Wall, and they’re flailing.

Rep. Chris Collins (R-N.Y.) tweeted this right after that same meeting.

They don’t have a plan. How many years have they been hollering about replacing Obamacare? I’m not good with big numbers.

The February 20 deadline is not completely impossible. Dylan Matthews at Vox explains how congressional Republicans have already paved the way for doing away with most of the ACA through reconciliation, which will allow them to pass the repeal with a simple majority vote in the Senate. For budget reasons they would have to retain the ACA’s cuts to Medicare providers, but everything else could go immediately. See also Sarah Kliff.

Lauren Fox at Talking Points Memo has a different take. I’m not sure if she’s talking about the same meeting, but it seems not everyone is on board.

In a closed-door meeting in the House basement Wednesday with the whip team, a Republican rank-and-file member rose to convey his deep fear that Republicans were making a big mistake by repealing the Affordable Care Act without any concrete plan to replace it with.

According to one source in the room, the member rose and got the room’s attention.

“You lose all leverage once you repeal this thing. There will be people on the left who will never help you replace it and there will be people on the right who aren’t going to help you either,” the member said. “We will own this thing and there will be consequences.”

(Consequences? What is this thing, consequences? We Republicans do not know this word.)

The House isn’t the only place where members are sounding the alarm. Sen. Rand Paul (R-KY), whose own state expanded Medicaid under the Affordable Care Act, said earlier this week that Republicans will be making a mistake if they repeal the Affordable Care Act without replacing it at the same time.

The concern is that by moving rapidly to repeal President Obama’s signature accomplishment, Democrats may never work with Republicans on a replacement. That could leave Republicans with two options, either they could change Senate rules and jam through their replacement or they will never get one.

If they go the delay route, there are still those alien consequences things to deal with. Josh Marshall wrote,

The AMA, which has been rather comically pro-Trump to date, came out today and told Republicans that they shouldn’t repeal Obamacare without a clear replacement. Notably, even two of the most conservative health care economists at AEI, came out yesterday and said that ‘repeal and delay’ would be a disaster. The truth is that “repeal and delay” is the policy equivalent of taking off from JFK to Heathrow with 2,000 miles worth of gas and saying you’re going to figure it out en route. No one who knows anything about health care economics, even people who are staunch free marketeers and hate Obamacare, think that makes any sense.

Note that recent polls say only 26 percent of Americans want the ACA repealed.

This morning President-Elect Trump is out with an ambiguous and possibly meaningless (it’s sort of like Being There) series of tweets warning Republicans to “be careful” and make sure that Democrats “own” the “ObamaCare disaster.” …

… They simply have no idea what to do and now they’re being taunted by Trump not to blow and he doesn’t have any idea either. It would be funny if millions of people’s lives and well being weren’t on the line.

For the Democrats, the plan seems to be to let the Republicans hang themselves. CNN:

President Barack Obama delivered a mandate to Democrats on Wednesday: “Don’t rescue” Republicans on Obamacare.

Less than three weeks out from leaving the White House, Obama visited Democratic lawmakers on Capitol Hill with a mission to save his signature healthcare reform law as Republicans are moving quickly to unroll the Affordable Care Act.

In the closed-door meeting, the President urged fellow Democrats to not “rescue” Republicans by helping them pass replacement measures, according to sources in the room.

He also floated this idea: Start referring to the GOP’s new plan as “Trumpcare.”

The suggestion was a clear indication of the Democratic Party’s goal of turning the tables on Republicans, who are already facing pressure to quickly craft a replacement bill.

Regrettably, that may be the best plan.

Update: Apparently Trump (via the Mouth of Sauron, a.k.a. Kellyanne Conway) he can fix things so that everybody who has insurance will still have insurance, and that people with pre-existing conditions will still be covered. Heh.

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