Healthcare bill will be known as Trumpcare

Reader feedback at end.

We previously reported on the American Health Care Act (AHCA) rollout, concluding that Republicans had gotten off to a shaky start in their “repeal and replace” efforts. First, conservative Republicans viewed this Obamacare Lite proposal as a sellout. Second, some of the GOP’s most promising ideas for bringing down healthcare costs – such as permitting the sale of healthcare insurance (HCI) policies across state lines to provide more competition – were being held for a second bill that would probably never be passed. GovCare replacement proposal falls short,
3/13/17.

Based on subsequent developments, AHCA with some conservative tweaks seems headed for House passage around March 23. But what will happen in the more liberal Senate and ensuing conference committee (to resolve differences between the House and Senate bills) remains very much “up in the air.” The Republicans relearn politics, Kimberly Strassel, Wall Street Journal,
3/16/17.

Is healthcare reform inevitable? No. But is it a lost cause? Not even close. Oh, this will be ugly and messy and painful. But only because that’s how real, old-fashioned politics works.

Discussion follows of developments last week and what may lie ahead.

A. The action – On March 13, a Congressional Budget Office memo was released that estimated enactment of the AHCA would reduce deficits by $337B over the next 10 years. This resulted from a major reduction in government outlays for healthcare, partly offset by the repeal of various taxes that were included in the Affordable Care Act. Here are some highlights for selected years:

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Were these results presented on a dynamic scoring basis, which the CBO memo says wasn’t done due to time limitations, they would look even more favorable as the spending reductions and tax reductions should – all other things being equal - promote stronger economic growth.

Great, except the deficit reductions would result primarily from reducing the number of Americans with healthcare insurance (HCI). Why the connection? Due to repeal of the individual mandate, fewer people would choose to acquire HCI policies or sign up for Medicaid. With repeal of the employer mandate, some employers would stop offering HCI coverage to employees. And most of the requirements for acceptable HCI policies would remain in effect, so there would be no near-term reductions in premiums to induce more signups. The CBO’s “educated guesses” as to the net effects on HCI coverage are shown below. American Health Care Act, Congressional Budget Office,
3/13/17 (download PDF).

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Democrats seized on the loss of coverage finding as justifying a “no” vote on the AHCA and vowed that this would be their position unless and until Republicans came to their senses. Democrats to GOP: Stop Obamacare repeal and we’ll negotiate, Susan Ferrechio, Washington Examiner,
3/14/17.

"If President Trump and Speaker Ryan and Majority Leader McConnell said we are taking repeal off the table, we would have a lot of people willing to sit down and improve the ACA, not repeal it," [Senate Minority Leader Chuck Schumer] said. "I have a lot of ideas, so do many of my colleagues in the House and the Senate. But if you repeal it first you are going to do huge damage and have nothing to replace it with. We are willing to make improvements."

In a somewhat similar vein, liberal media outlets blasted the AHCA as a scheme to balance the budget on the backs of the needy and disadvantaged. Trumpcare, Ryancare, Trashcare, D. Watkins, salon.com,
3/19/17.

According to the CBO analysis, the AHCA would “reduce federal deficits by $337 billion over the coming decade and increase the number of people who are uninsured by 24 million in 2026 relative to current law.” And every Republican is running to the cable news networks, bragging about saving $300 billion.

For their part, conservative Republicans (whose votes would be essential to pass the bill in the House) saw the CBO findings as evidence that efforts to craft a “middle of the road” proposal had been misguided and the GOP should shift to the outright “repeal” and then we can decide how to fix it approach they had favored from the outset. CBO score makes the case for full repeal and free market replacement, Philip Klein, Washington Examiner,
3/14/17.

How could a Republican plan that spends hundreds of billions of dollars offering tax credits to individuals and winds down Obamacare over several years cover no more people than a straight, immediate, full repeal would have? The reason is that the Republican replacement preserves many of Obamacare's regulations that drive up the cost of insurance. So, in essence, the GOP alternative would be asking people to purchase expensive Obamacare plans, with less financial assistance. In contrast, while full repeal would offer no assistance, because it would get rid of Obamacare's regulations, it would make insurance cheaper.

Meanwhile Speaker Paul Ryan et al. pressed ahead with a vote in the Budget Committee, the last major hurdle remaining before bringing the AHCA to the House floor. The bill squeaked through despite some conservative opposition. House Budget Committee passes Obamacare bill with three GOP defections, Robert King, Washington Examiner,
3/16/17.

There was no shortage of sentiment that the president would be well advised not to follow Speaker Ryan’s lead on this matter, but instead retain flexibility to shift his position as matters developed while finding other issues on which to spend his political capital. For example:

• Can Paul Ryan pull this off, or is he headed for a brutal defeat? Paul Kane, Washington Post,
3/15/17.

“If you don’t believe it’s better than Obamacare over the long haul, if you think you’re going to own it for the rest of your life, President Trump, it will be called Trumpcare, don’t buy it,” Sen. Lindsey O. Graham (R-S.C.) told conservative radio host Hugh Hewitt on Wednesday. Graham argued for just letting the existing ACA markets collapse, hoping that would provide the political momentum for more far-reaching legislation that even some Democrats would support, given the urgency.

•Healthcare threatens to complicate Trump, Ryan relationship, Sarah Westwood & David Drucker, Washington Examiner,
3/16/17.

For conservative critics of the bill, Ryan is a convenient scapegoat. It's why they've taken to calling the AHCA "Ryancare" rather than "Trumpcare" (Democrats are referring to by the latter nickname.). They need Trump to support conservative changes to the bill that might go against his own inclinations to provide expansive coverage. 

• Congress leads Trump down wrong path, Byron York, Washington Examiner,
3/14/17.

All across the capital, politicos are arguing about what House Republicans should do next in the Obamacare fight. *** It has become mind-numbingly complicated. And perhaps the answer to all those questions is one simple sentence: Republicans are working on the wrong thing. And the Republican president is allowing himself to be distracted from delivering early and often on his core campaign promise of improving the economy and bringing jobs to millions of Americans.

Far from holding back, however, the president jumped into the fray, expressing full support for the AHCA and actively working to convince conservative holdouts. Trump wins over Republican Study Committee members on healthcare bill, Gabby Morrongiello, Washington Examiner,
3/17/17.

"I want everyone to know that every single person in this room is now a 'yes,'" Trump said during his meeting with more than a dozen [Republican Study Committee] members. *** The president noted that "certain changes" were made to court the 13 conservative lawmakers who met with him on Friday, while declaring that Obamacare is now a "dead healthcare plan." *** "I want everyone to know, I'm 100 percent [elsewhere quoted as 1,000 percent] behind this," he said in the meeting. "I want everybody to know that the press has not been speaking properly about how great this is going to be."

The House Freedom Caucus (about 40 staunch fiscal conservatives) is reportedly still against the AHCA, but concessions agreed to at the White House meeting on Friday may win enough of them over to carry the day. House Freedom Caucus says it remains opposed to GOP healthcare plan, Kyle Feldscher, Washington Examiner,
3/17/17.

House Majority Whip Steve Scalise announced Friday he had made a deal with 12 members of the Republican Study Committee and the House Freedom Caucus in order to get their support. *** The deal was made during a meeting with President Trump at the White House . . .

B. The outlook – It seems likely that a modified version of the AHCA will pass the full House this week albeit by a narrow margin. Trump gives shot of confidence to flagging health[care] bill, Robert King, Washington Examiner, 3/18/17.

Key to getting the study committee leadership's support was two major additions to the bill: mandatory work requirements for Medicaid and giving states the choice between per capita caps or block grants for federal Medicaid funding.

But then what? Some Senate Republicans are worried about the CBO’s findings and envision major changes designed to achieve higher levels of HCI coverage. GOP senators suggest changes for healthcare bill offered by House, Jennifer Steinhauer & Thomas Kaplan, New York Times,
3/14/17.

A day after a harsh judgment by the Congressional Budget Office on the House plan to repeal the Affordable Care Act, nervous Senate Republicans on Tuesday suggested changes to the bill. They [John Thune of S. Dakota and Bill Cassidy of LA are mentioned by name] told Trump administration officials — including the health secretary, Tom Price — that they wanted to see lower insurance costs for poorer, older Americans and an increase in funding for states with high populations of hard-to-insure people. They said those changes would greatly improve the chances of Senate approval even though they might further alienate conservatives.

Other Republicans are pushing for conservative changes, which would provide more choice and competition in the healthcare markets. See, e.g., the suggestions of Sen. Ted Cruz (R-TX) and Rep. Mark Meadows (R-NC) of the House Freedom Caucus, as recapped below. Three criteria for health[care] reform: The House repeal-and replace plan doesn’t go far enough, Ted Cruz & Mark Meadows, Wall Street Journal, 3/15/17.

(1) Lower HCI premiums by repealing all of the Affordable Care Act requirements for compliant coverage versus leaving most of them in effect, allowing families to pay for HCI from expanded health[care] savings accounts, and enabling consumers to purchase HCI across state lines. (2) In lieu of the currently proposed tax credits (a new entitlement for qualifying individuals), create nonrefundable tax credits that can be used to reduce payroll tax liability for lower earners. (3) Freeze Medicaid expansion under the ACA immediately (rather than in 2020), and block grant state Medicaid programs (this last idea has since been accepted).

Even using the reconciliation process, which will make the AHCA filibuster-proof, the Republicans will need at least 50 votes (plus a tie-breaker vote by the vice president) to carry the day. With a slim 52-48 majority and assuming unanimous Democratic opposition, three or more defections would spell defeat. And three Republican senators – moderates Susan Collins of ME & Dan Heller of AZ, and conservative Rand Paul of KY – have already announced that they plan to vote against the bill. Republican Sen. Dan Heller won’t vote for health[care] plan, Robert King, Washington Examiner,
3/17/17.

Although a healthcare bill could fail in the Senate, we believe the president will find a way to break the moderate/conservative impasse – even if it means accepting some amendments to the AHCA that conservative Republicans in the House won’t much like. Otherwise, Republicans would face major reverses in the 2018 mid-term elections and beyond – and everyone knows it. The Republican Obamacare choke, Daniel Henninger, Wall Street Journal,
3/15/17.

If this bill [AHCA] fails, there is only one Plan B. It will be a single-payer system enacted after 2020 with votes from what’s left of the Republican party after—Donald Trump is right about this—they get wiped out in 2018 and lose the presidency two years later. After blowing it on Obamacare, why would anyone vote for them again?

If a bill is passed by the Senate, with whatever changes may be proposed and agreed to, a Senate/House conference committee would be convened to reconcile the differences between the two bills. With a light congressional schedule in April, it’s hard to imagine a final bill being sent to the president’s desk before May at the earliest.

As discussed last week, a good case could be made for expanding the healthcare bill to include reform ideas that are currently being deferred for a second bill (subject to a Senate filibuster) on grounds that they aren’t sufficiently budget related. It would be foolish to allow excessive deference for the procedural technicalities involved to govern the substance of what will probably be the only healthcare reform bill enacted. Other conservatives have made the same point. See, e.g., Cruz & Meadows,
op. cit..

We should follow the text of the Budget Act, which establishes the reconciliation process. Fully repealing the insurance mandates would comply with both the letter and the spirit of the statute. More important, the Senate parliamentarian does not ultimately determine what is allowable under reconciliation. That authority falls to the Senate and the vice president, the chamber’s presiding officer. As the former Senate parliamentarian Robert Dove once explained, the vice president is “the ultimate decider” on reconciliation: “The parliamentarian only can advise. It is the vice president who rules.”

For more about the conversation that has taken place on this subject, see Republicans’ Obamacare repeal fight turning into battle over Senate procedures, Philip Klein, Washington Examiner,
3/16/17.

Fixing the deficiencies of GovCare is a complicated subject, and all concerned may need to give some ground. To this end, it has been suggested that the president should reach out to Democrats and solicit their support – ignoring the precedent that they set by enacting the Affordable Care Act in 2010 without a single Republican vote – in order to achieve a lasting solution. Reach across the aisle, Mr. President, Peggy Noonan, Wall Street Journal,
3/16/17.

If it worked, Mr. Trump would crow he’s made the first big bipartisan deal in a generation—it’s a new day. It might help on future bipartisan efforts, such as infrastructure spending. And he can make it up to Republicans with conservative regulatory and tax reform.

Count us as skeptical of this notion, at least until Democrats demonstrate interest in participating in the process, but we would applaud the manner in which the president has engaged with interested parties on healthcare reform. Remarks by the president in listening session on healthcare [after which, participants got a chance to share their personal experiences with the president and his aides listening],
3/13/17.

We’re not going to have one-size-fits-all.  Instead, we’re going to be working to unleash the power of the private marketplace to let insurers come in and compete for your business. *** More competition and less regulation will finally bring down the cost of care, and I think it will bring it down very significantly. Unfortunately, it takes a while to get there, because you have to let that marketplace kick in, and it’s going to take a little while to get there.  Once it does, it’s going to be a thing of beauty.

What a contrast with the healthcare summit early in the previous administration. Note the one-way nature of the communications in that case. A tale of two summits [re fiscal responsibility and healthcare, respectively],
3/16/09.

President Obama was introduced and addressed the participants about the need for a comprehensive overhaul of the healthcare system, which he characterized as not only “a moral imperative” but also a “fiscal imperative” in order to “get our federal budget under control.” (In hindsight, this plan didn’t work very well.)

No sacrifices by healthcare consumers were called for: “[If] somebody has insurance they like, they should be able to keep that insurance . . . keep their doctor . . . just pay less.” (Again, these ideas didn’t pan out.)

And the only obstacle was said to be overcoming “entrenched interests” [presumably healthcare providers and insurance companies] so “we will not “arrive back at the same stalemate that we've been stuck in for decades.”

Participants were then sent off to breakout sessions to talk among themselves, after which there was a wrap-up session featuring remarks by the president and Senator Ted Kennedy (D-MA).

It would be hard to live up to President Trump’s hype, but our guess is that Trumpcare would be a major improvement over the current healthcare system – which is top-down driven, grossly inefficient, and fiscally unsustainable. Let’s hope a majority in Congress will participate in shaping the proposal and then support its enactment and implementation.

**********FEEDBACK**********

#I don’t agree that “Republicans must pass a healthcare bill or else," as suggested in the summary of the entry (and weekly tweet). Many can make political points from opposing a compromise bill, although in some districts a vote against such a bill would jeopardize their seats. Accordingly, a proper Republican candidate must be willing to fight for that seat and keep it in Republican hands. – SAFE director

If Republicans don’t follow through on promises to “repeal and replace” GovCare, this will not go unnoticed. President Trump is proceeding accordingly. See, e.g., Trump gets revved up for Hill meetings on Obamacare bill: “We’ve gotta get this one done,” Pete Kasperowicz, Washington Examiner, 3/21/17.

#You are exactly correct--Thursday is a "make or break "day-- We had better be adding extra prayers tonight for the passage of these proposals! - Widow of DuPont retiree

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