Here They Go Repealing the Affordable Care Act. And How Is That Going?

15977995_1081116692017989_1435982330398986180_nFirst, as the GOP and the Democrats in Congress continue their battles, let me say that the childish behavior that both sides are exhibiting truly is an embarrassment. No wonder nothing ever gets done in our government or takes so long and wastes so much money. The disrespect shown to the President-Elect and his Conferees is embarrassing and childish. Congressman Lewis of Georgia, and his statements that President –Elect Trump is not a “legitimate president” is unbelievable as well as the Democrats still looking for excuses for Hilary Clinton’s loss- hacking, emails leaked, Russian influence, the Chinese! Doesn’t anyone understand that the election, the Electoral College, the Constitution has determined that Mr. Trump won the election and he is now our President-Elect? And let us not forget the GOP, who is threatening to repeal the Affordable Care Act/ Obamacare as they are drooling with the idea of embarrassing President Obamacare- and without an alternative healthcare system to cover our patients.

So, now the latest round in the epic health care battle has begun…and continues as the GOP Congress has approved the first step toward dismantling the Affordable Care Act. By a near party line 227-198 vote, the House approved a budget Friday that prevents Democrats from using a Senate filibuster to derail a blueprint that would repeal and replace President Barack Obama’s signature healthcare law. Nine Republicans joined all voting Democrats in opposing the budget. The Senate approved the measure last Thursday. It does not need the president’s signature. Friday’s passage was critical because it takes 60 votes to end filibusters, while Republicans have a 52-48 Senate majority.

Now, Republicans in Congress must decide which parts of Obamacare to end and how to help protect up to 30 million people who received coverage under the ACA’s provisions and its Medicaid expansion. Many in the party have split over how to reform the nation’s $3 trillion-a-year health care system. Still, President-elect Donald Trump has urged Republicans to pass the budget and concurrently find a replacement plan. “The ‘Unaffordable’ Care Act will soon be history!” Trump tweeted Friday. He takes the presidential oath next Friday.

Tammy Luhby reports that after decades of circling each other, the Democrats gained the upper hand in 2010, making their philosophy of universal health care coverage the law of the land. They called it the Affordable Care Act. Now the advantage lies with the Republicans, who suddenly have the opportunity to advance their brand of universal health care access. The names of the repeal legislation floated over the years provide insights into their priorities. The Empowering Patients First Act. The Healthcare Accessibility, Empowerment, and Liberty Act. The Patient CARE Act.

Senate Republicans took their first major step toward repealing the Affordable Care Act on Thursday, approving a budget blueprint that would allow them to gut the health care law without the threat of a Democratic filibuster. The vote was 51 to 48. During the roll call, Democrats staged a highly unusual protest on the Senate floor to express their dismay and anger at the prospect that millions of Americans could lose health insurance coverage.

One by one, Democrats rose to voice their objections. Senator Maria Cantwell of Washington said that Republicans were “stealing health care from Americans.” Senator Ron Wyden of Oregon said he was voting no “because health care should not just be for the healthy and wealthy.” The presiding officer, Senator Cory Gardner, Republican of Colorado, repeatedly banged his gavel and said the Democrats were out of order because “debate is not allowed during a vote.” The final vote, which ended just before 1:30 a.m., followed a marathon session in which senators took back-to-back roll call votes on numerous amendments, an arduous exercise known as a vote-a-rama.

The approval of the budget blueprint, coming even before President-elect Donald J. Trump is inaugurated, shows the speed with which Republican leaders are moving to fulfill their promise to repeal President Obama’s signature domestic policy achievement — a goal they believe can now be accomplished after Mr. Trump’s election.

The action by the Senate is essentially procedural, setting the stage for a special kind of legislation called a reconciliation bill. Such a bill can be used to repeal significant parts of the health law and, critically, is immune from being filibustered. Congress appears to be at least weeks away from voting on legislation repealing the law.

Republicans say the 2016 elections gave them a mandate to roll back the health care law. “The Obamacare bridge is collapsing, and we’re sending in a rescue team,” said Senator Michael B. Enzi, Republican of Wyoming and the chairman of the Senate Budget Committee. “Then we’ll build new bridges to better health care, and finally, when these new bridges are finished, we’ll close the old bridge.”

Lets look at how Republicans Can Repeal Obamacare Piece by Piece Peeling away pieces of the law could lead to market chaos and Republican leaders say they will work closely with Mr. Trump developing legislation to repeal and replace the health care law, but it is unclear exactly how his team will participate in that effort.

On Wednesday of last week, Mr. Trump said he would offer his own plan to repeal and replace the law “essentially simultaneously.” He said he would put forth the plan as soon as his nominee for secretary of health and human services, Representative Tom Price, Republican of Georgia, is confirmed. The Affordable Care Act has become ingrained in the American health care system, and unwinding it will be a formidable challenge for Republicans. As I have pointed out, more than 20 million people have gained coverage under the law, though premiums have risen sharply in many states and some insurers have fled the law’s health exchanges. The budget blueprint instructs House and Senate committees to come up with repeal legislation by Jan. 27.

Senator Bob Corker, Republican of Tennessee, and four other Republicans had sought to extend that deadline by five weeks, to March 3. But late Wednesday night, Mr. Corker withdrew an amendment that would have changed the date. “We understand that everyone here understands the importance of doing it right,” he said. He described the Jan. 27 date in the budget blueprint as a placeholder.

Senator Rob Portman of Ohio, another Republican who sought to delay the deadline, said: “This date is not a date that is set in stone. In fact, it is the earliest we could do it. But it could take longer, and we believe that it might.” The House was planning to take up the budget blueprint once the Senate approved it, though some House Republicans have expressed discomfort with voting on the blueprint this week because of lingering questions over how and when the health care law would be replaced.

A vote on the measure in the House did come on Friday. In its lengthy series of votes, the Senate rejected amendments proposed by Democrats that were intended to allow imports of prescription drugs from Canada, protect rural hospitals and ensure continued access to coverage for people with pre-existing conditions, among other causes.

In the parlance of Capitol Hill, many of the Democrats’ proposals were “messaging amendments,” intended to put Republicans on record as opposing popular provisions of the Affordable Care Act. The budget blueprint is for the guidance of Congress; it is not presented to the president for a signature or veto and does not become law.

As the Senate plowed through its work last Wednesday, Republicans explained why they were determined to dismantle the health care law, and they tried to assuage concerns about the future of coverage for millions of Americans. “This is our opportunity to keep our campaign promise,” said Senator Roger Wicker, Republican of Mississippi. “This is our opportunity to help the president-elect and the vice president-elect keep their campaign promises and show to the American people that elections have consequences.”

Senator Johnny Isakson, Republican of Georgia, said that while working to repeal the health care law, “we must also talk about what we replace it with, because repealing it without a replacement is an unacceptable solution.” Republicans do not have an agreement even among themselves on the content of legislation to replace the Affordable Care Act, the timetable for votes on such legislation or its effective date.

Senator Susan Collins, Republican of Maine, said on Wednesday that she agreed with Mr. Trump that Congress should repeal the health law and adopt a replacement plan at about the same time. “But I don’t see any possibility of our being able to come up with a comprehensive reform bill that would replace Obamacare by the end of this month,” she said. “I just don’t see that as being feasible.” (Ms. Collins also supported pushing back the deadline to come up with repeal legislation.)

As Republicans pursue repealing the law, Democrats contend that Republicans are trying to rip insurance away from millions of Americans with no idea of what to do next. The Senate Democratic leader, Chuck Schumer of New York, called the Republicans’ repeal plan “irresponsible and rushed” and urged them to halt their push to unravel the law.

“Don’t put chaos in place of affordable care,” he said.

While the Republicans have yet to issue a detailed plan to replace Obamacare, many of their proposals share common traits. CNNMoney lays them out for you as a guide to the Congressional battle that lies ahead.

  1. Universal coverage vs. universal access:

A primary goal of Obamacare was to make sure all Americans — or nearly all — obtained health insurance. It created insurance exchanges for those seeking individual coverage and expanded Medicaid for low-income adults. It offered a mix of incentives and penalties to entice people to sign up.

Republicans have a different take. Rather than emphasizing coverage, they back making health insurance more accessible. They promise to lower the cost of premiums to make coverage more affordable so that more people can buy policies.

  1. Comprehensive benefits vs bare bones coverage:

Obamacare requires that insurers cover lots of benefits that were hard to find in the individual market beforehand. Think: maternity care, mental health and prescription drugs. Under Obamacare, Americans can get preventative services, such as annual check-ups, cholesterol screening and certain vaccines, for free.

The law also provides other protections for Americans. It caps how much consumers paid out of pocket each year and ended insurers’ practice of placing a dollar limit on how much they paid annually or over one’s lifetime.

Related: How Trump’s health secretary pick would replace Obamacare- this I already covered in a previous post. Go back and read it again.

Republicans argue mandating such comprehensive benefits drive up cost. They want to give consumers more choice. They say Americans should be able to pick the benefits they want — why should a 55-year-old couple pay for maternity benefits?

This increased flexibility will likely mean lower premiums, though it could also mean higher deductibles. But that’s okay with Republicans, who tout the concept of consumer-directed health care. The more people have to pay out of pocket, the wiser spending choices they’ll make, the thinking goes. If people have to shell out $75 for a blood test, they’ll think twice about whether they really need it or they will shop around to see if they can get it cheaper elsewhere.

  1. Premium subsidies vs. tax credits:

Under Obamacare, the federal government provides a helping hand for low- and moderate-income enrollees in the form of premium subsidies, which are officially tax credits offered in advance. The less you earn, the higher the subsidy. More than eight in 10 Obamacare enrollees get premium subsidies, which lower their cost to less than 10% of their income.

The Republican replacement plans also provide tax credits to cover premiums. But the size of the Republican credits would be based on age, not income. Younger enrollees would get less than those age 50 and over.

Also, to help pay for coverage, Republicans would encourage the use of a favored tool: health savings accounts. HSAs allow people to sock away funds tax free for medical expenses. But higher-income Americans, who can afford to contribute to them, mainly use it. Think of it most people don’t have the pre-tax dollars or the knowledge to purchase HSAs. They are paying mortgages, rents, car payments, cell phone payments, the cost of raising children and putting their kids through school, food and other insurance, etc.

  1. Pre-existing conditions ban vs. continuous coverage:

Obamacare barred insurers from discriminating against those with pre-existing conditions. Insurers could not reject those who had been sick, nor charge them more.

Republicans say they would protect people with pre-existing conditions — if they’ve maintained continuous insurance coverage. That means if you have a gap in coverage — say, because you left your job and couldn’t afford coverage on the individual market — you might not be protected.

Those who are uninsured and sick may be charged more or may have to look for coverage through state high-risk pools, which had a very troubled history before they were essentially disbanded after Obamacare’s individual exchanges opened in 2014.

  1. Taxing high-cost employer plans vs. capping tax deduction:

Many lawmakers on both sides of the political aisle want to rein in the cost of employer-sponsored insurance plans, which cover 150 million Americans. These plans often offer rich benefits packages, which employees like to utilize, driving up the nation’s health care spending.

Obamacare called for instituting the so-called Cadillac Tax. It would impose a 40% levy on the amount of employer premiums above $10,200 for individual and $27,500 for family policies. The idea is to have employers limit their benefits packages to a certain level, slowing the growth of health care spending and usage.

But even though the Cadillac Tax is in President Obama’s landmark health reform law, it is not universally endorsed by Democrats. In fact, Congress came together to push back the date the tax is to go into effect to 2020, from 2018.

Republicans, on the other hand, would limit costs in employer plans by capping the tax deduction for premiums. The rationale is that this will force employers to provide less generous policies so their workers don’t get socked with a tax bill.

  1. Medicaid expansion vs fixed grants:

In keeping with its universal coverage philosophy, Obamacare aimed to expand Medicaid to all adults with incomes below 138% of the poverty level. Prior to Obamacare, most enrollees were low-income children, pregnant women, parents, the disabled and the elderly. The federal government enticed states by covering 100% of the cost of the newly eligible for three years and lowered reimbursement to 90% over time.

Republicans have long favored turning Medicaid into a grant program. They would either provide states with a set amount of funds, known as a block grant, or provide a certain amount of money to cover each enrollee, which is called a per-capita grant. This would help curtail the growth of Medicaid spending and make it a more predictable cost for the federal government. But consumer advocates worry that funding caps will restrict the number of people who can enroll and the quality of care they receive.                                                                                                                     House Speaker Paul Ryan has said that Republicans will “definitely” put a replacement for ObamaCare on Donald Trump’s desk before the end of April. Or perhaps we should say “replacements.”

The biggest mystery in Washington these days isn’t Russian spies or whom Trump will tap for the Supreme Court. The real head-scratcher: how Republicans will replace ObamaCare.

Initially, the GOP was planning to eat dessert first. They were going to repeal the law, bringing the political and tax benefits at once, but delay the actual elimination of benefits for at least two years while they worked out a plan.

But an uproar among conservatives who sensed danger from creeping repeal and Trump’s apparent agreement sent Congressional policy wonks back to the drawing board.

And now Kentucky Sen. Rand Paul vowed last night that he would reveal a bill to replace ObamaCare next week. Paul, a Republican, tweeted a photo of the first page of the bill he titled the “Obamacare Replacement Act.” He added: “Done drafting the bill & will be discussing on CNN Sunday AM and all week next week!”Last week, Paul was the lone Republican to vote against the budget which would repeal the Affordable Healthcare Act after expressing his displeasure because it endorsed huge budget deficits. He wasn’t the only one to have expressed anxiety over dismantling the law without a replacement to show voters.                                                                                                                                                 Sen. Susan Collins, R-Maine, said she wants at least to see “a detailed framework” of a GOP alternative health care plan before voting on repeal. She said Republicans would risk “people falling through the cracks or causing turmoil in insurance markets” if lawmakers voided Obama’s statute without a replacement in hand. The budget “gives us the tools we need for a step-by-step approach to fix these problems and put Americans back in control of their health care,” House Speaker Paul Ryan, R-Wis., said after the vote. Congressional Republicans have made annulling Obama’s law and replacing it a top goal for the past seven years. GOP rifts and an Obama veto prevented them from achieving anything other than holding scores of votes that served as political messaging.                                                                                                                            President-elect Donald Trump also made targeting Obama’s statute a primary target during his campaign. At his news conference Wednesday, Trump — who’s supplied few details of what he wants — said his emerging plan will be “far less expensive and far better” than the statute. And I say-show me!                                                                                           Many Republicans have insisted on learning how their party will re-craft the nation’s $3 trillion-a-year health care system before voting to void existing programs. There are internal GOP chasms over Republican leaders’ plans to use their bill to halt federal payments to Planned Parenthood and pare Medicaid coverage. There are also disagreements over how to pay for the GOP replacement, with many Republicans leery of Ryan’s proposal to tax part of the value of some health insurance provided by employers.                                                                    “Repeal and eventually replace” seems to be dead, at least for the time being.     Slow-walking the repeal had obvious political benefits. First, it would have allowed Republicans to avoid major disruptions in coverage as they built consensus around a new plan. Second, delaying the fight over what to put in its place would have left lots more bandwidth for Republicans to take up other policy priorities like taxes, border security and infrastructure. Third, and perhaps most importantly, twinning repeal and replacement is risky business and again remember my advice, as in Pottery Barn, you break it you buy it and the GOP will take the blame!

Also, remember the analogy about choosing a restaurant. If a group is trying to decide where to dine and is given three options, say the new Indian place, Applebee’s or “something else,” “something else” is an easy winner. That’s because everyone in the group believes their preferred outcome still might be obtained.

Ryan’s initial plan was, essentially, just to get Republicans to agree that they wanted to go out to dinner in the first place and then start the debate about where to go once everyone was in the car.

Once you start talking about the specifics of ObamaCare’s replacement, you start jeopardizing votes for the repeal itself. Maine moderate Sen. Susan Collins and Nebraska conservative Sen. Ben Sasse both want the law repealed, but do not necessarily agree on the replacement. The GOP can only afford to lose two votes in the Senate on repeal, and running a concurrent replacement dramatically increases the chance of defections.

In what would be one of the most ambitious legislative undertakings in memory, Ryan and his team planned to put forward not one “comprehensive” plan, but rather a suite of related bills as a replacement package. This is a reversal of decades of congressional practice in which important or complicated legislation, like ObamaCare itself or two failed bids to reform immigration are heaped into enormous piles. Republicans had good fun with Democrats over the length of ObamaCare: some 2,700 pages of indecipherable Beltwayeze.

But both parties knew the secret to passing unpopular or controversial things was size. Written correctly and with enough stuffing you could hide a black bear in one of these bills. In the old days, bills were crafted in legislative backrooms and delivered with no time to be reviewed by the members or the public. Lawmakers could vote for one of these nasties and then go home and tell the good people of their district the story they wanted.

Now, there is scrutiny at every stage. Closed-door meetings turn into leakfests on social media. Activists and journalists pore over draft language and voters respond in real time to various outrages they see in the plans.

In a nod to the new reality, Ryan is proposing a series of smaller bills passed one at a time. It’s also a nod to the fact that Republicans can act alone to repeal, they will need Senate Democrats’ help to replace.

The risks are still substantial. Democrats will have many more opportunities to obstruct the majority so the possibility of a legislative quagmire is real. The safety net here is that if Democrats and dissident Republicans succeed in blockading key components, the leadership can fall back to delayed replacement. Whatever happens, though, the next three months promise to bring a wild, wide-ranging fight over the law. Ryan and his Senate counterpart Mitch McConnell are tasked with avoiding what happened eight years ago where early momentum for ObamaCare stalled and eventually turned into a politically bruising slog.

As they say in Triadelphia: You know how you eat an elephant? One bite at a time.

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