So, this week the GOP persisted with their intent and promise to repeal the Affordable Care Act. Very stupid!!
On its front page, the New York Times, Kaplan and Pear reported that on Thursday, the House “narrowly approved” the American Health Care Act by a vote of 217-213, “as Republicans recovered from their earlier failures and moved a step closer to delivering their promise to reshape American health care without mandated insurance coverage.” The article says no Democrats voted for the bill. 20 Republicans joined them. The Times adds that this passage “keeps alive the Republican dream to unwind” the Affordable Care Act. But the bill “faces profound uncertainty in the Senate, where the legislation’s steep spending cuts will almost certainly be moderated.”
Mr. Shesgreen of USA Today reports that the vote “reflected sharp divisions over the GOP’s proposal, which is a long way from becoming law but still represents a huge victory for House Republican leaders and the Trump administration.” Republicans have “struggled for months to cobble together legislation that would garner the required 216 votes from its own fractured conference.”
Sullivan, Weigel, O’Keefe in the Washington Post reported that the approval of the AHCA “capped weeks of fits and starts for the GOP and represented an enormous victory for President Trump, who repeatedly pledged on the campaign trail last year to repeal and replace” the ACA “but has struggled to secure legislative wins early in his presidency.”
Ehrenfreund in the Post, in a separate article further reported that the AHCA was passed without “an official estimate of how the bill will affect the federal government’s bottom line or how many Americans could go without insurance under the plan.” Therefore, it remains unclear “whether the legislation would save the government money or add to the national debt.” The Congressional Budget Office has “not had time to put together” its “usual estimate of the costs and savings, and independent analysts are uncertain about what the results would be.”
After seven years of repeal-and-replace rhetoric against the Affordable Care Act, two presidential campaigns waged for and against it and a recent high-profile failure, House Republicans passed their bill.
The trouble is this bill is unlikely to ever become law — at least in its current iteration.
Here’s why: While the bill passed the House (narrowly) Thursday afternoon, it still has to go to the Senate. It’s being done with a wink and a promise that the Senate will overhaul substantial portions of the bill.
“This thing is going to the United States Senate. It’s going to change in my view in the United States Senate in some way,” Rep. Tom Cole of Oklahoma, a deputy whip in the House, told NPR’s Morning Edition. (Cole is one of the people in charge of making sure Republicans have the votes.) “Then we have to have a conference to work out the differences. If we can do that, then it has to still pass the House and the Senate again before it ever gets to the president. So at some point, you just have to move.
Sure, the Senate is controlled by Republicans, also, but they have an even slimmer majority there with equally fractious divisions. If they lose three votes, the bill goes down. Sen. Tom Cotton of Arkansas has been doing a delicate dance on Medicaid expansion. His state took federal money to expand Medicaid, but he has called it a “welfare program” and said “able-bodied adults” shouldn’t be on it.
After an angry town hall, he changed his tune, saying the House bill was “moving too fast; I didn’t think it got it right.” He also has indicated he is against it in its current form because, “I simply think that it’s not going to work to bring down premiums for working Arkansans or working Americans around the country.”
Other senators, like Lisa Murkowski of Alaska, Susan Collins of Maine, Bob Corker of Tennessee, Rob Portman of Ohio and Bill Cassidy of Louisiana, are in favor of repeal, but they want something “stable” to replace it. They have indicated that affordability, coverage and rural access (like what the bill means for rural hospitals) are key.
Senate Majority Leader Mitch McConnell is going to allow amendments. That means the bill will change. And if even a comma is inserted, it has to pass the House — again.
And that is inevitably going to bring back this whole game of whack-a-mole in the House.
Wait, there’s more. Because Democrats aren’t going to sign on to something that guts the coverage mandates of the Affordable Care Act, Republicans can’t get 60 votes to advance the legislation.
So to pass it, they’re going to have to use the process known as reconciliation. That allows legislation to pass with just a majority (plus one). But there’s a catch — it has to be tied to the budget.
Get ready to hear a whole lot more about the “Byrd Rule.” What’s that? The Committee for a Responsible Federal Budget explains it this way:
“Although reconciliation bills are granted many privileges that are not available to most other legislation (see Reconciliation 101), they remain bound by several conditions. Some of these restrictions championed by former Senator Robert Byrd (D-WV) and established in Section 313 of the Budget Act are jointly referred to as the ‘Byrd Rule.’ The Byrd Rule disallows ‘extraneous matter’ from being included in a reconciliation bill, extraneous matter being defined in three major categories of restrictions.
“First, reconciliation legislation must only involve budget-related changes and cannot include policies that have no fiscal impact, that have ‘merely incidental’ fiscal impacts, or that increase the deficit if the committee did not follow its reconciliation instructions (including proposals outside of a committee’s proper jurisdiction—more on this below). Second, reconciliation bills cannot change Social Security spending or dedicated revenue, which are considered ‘off-budget.’ And finally, provisions in a reconciliation bill cannot increase the deficit in any fiscal year after the window of the reconciliation bill (usually ten years in the future) unless the costs outside the budget window are offset by other savings in the bill.”
The umpire of what qualifies under the Byrd Rule is the Senate parliamentarian. Her name is Elizabeth MacDonough. Politico wrote of her in 2015: “She may very well be the most powerful person in Washington in determining how far Republicans can go in trying to repeal Obamacare. As the Senate parliamentarian, MacDonough will make the decisions on which pieces of the law qualify to be repealed using a complicated budget procedure called reconciliation. Her decisions would allow Senate Republicans to vote to kill major provisions of the health care law under a simple 51-vote majority without giving Democrats a chance to filibuster.”
MacDonough was appointed in 2012, and even though she is liked on Capitol Hill by both sides, past parliamentarians (known colloquially on the Hill as “parls”) have come under fire because the majority party didn’t like how they ruled. More from Politico:
“Republicans protested decisions by then-parliamentarian Alan Frumin in the 2010 health care reform fight, when Democrats used the budget fast-track tool to pass a small part of the Affordable Care Act. In 2001, Republicans fired Robert Dove as parliamentarian after he ruled against them on how many reconciliation bills could be used. That was actually his second stint in the job: Democrats had fired Dove when they took the majority in 1987.”
Reconciliation — and what fits and doesn’t fit into it — isn’t the GOP’s only complication. Their biggest one is the policy itself. It has a lot of shortcomings. The nonpartisan Congressional Budget Office said of the last iteration of the House bill that it would save money but leave some 24 million without insurance.
So the GOP bill would be less generous in terms of benefits and cover fewer people. And the only reason it would save money is that the repeal bill would cut $880 billion from Medicaid. That would break President Trump’s promises of “insurance for everybody” and “no cuts to Social Security, Medicare & Medicaid.”
The CBO won’t get out an analysis of the bill before Republicans are planning to vote. Politically, that gives them a chance to wipe their brows and not have to defend something that could be difficult to defend.
It’s morally questionable, though, to vote on something without knowing its cost or consequences. And what happens when the CBO score does come out — and they’ve already voted for it without the opportunity to make changes?
And there’s the issue of the popular pre-existing conditions provision in Obamacare — which requires insurance companies to cover people with pre-existing conditions.
Trump claimed as late as this week that this bill would guarantee that people with pre-existing conditions would continue to be covered. But Republicans’ attempts at doing that are very different from the way Obamacare achieves it.
The GOP plan would essentially allow states to take sicker people out of the broader pool of people buying coverage and put them into a “high-risk pool.” That, in theory, would bring down the cost of insurance for healthier people, but drive up the cost for the sick. Depending upon how much costs increase, that could shut some or many of the people who definitely need health care out of the insurance market.
High-risk pools haven’t shown great results where they have been currently implemented. Part of the problem has been funding. That’s why Trump picked up two more votes with a proposal for $8 billion more for those pools, but experts say that’s most likely not even enough.
The U.S. government already has very high profile high-risk pools, Medicare and Medicaid. Medicare — health care for the elderly — is popular but expensive.
A big point of Obamacare was to not go down that potentially problematic funding lane. Healthier people might pay a little more, but if you got sick, it wouldn’t bankrupt you.
So why the rush to get this through if it has all these holes and may not be what eventually becomes law anyway? Politics. The House finally has a chance to tell its base it did something, it passed something to repeal and replace Obamacare.
The House goes on recess next week, and Republicans want to get this done and hand President Trump a win before then.
It’s a huge relief for House Speaker Paul Ryan, who was feeling the heat of not being able to govern House Republicans. It’s a huge relief for Trump, who has been made to look ineffectual with no legislative wins to speak of in his first 100 days and little other major accomplishments in that time — despite Republicans being in charge of the White House, House and Senate.
However, hours after the GOP-controlled House narrowly passed a bill to repeal and replace ObamaCare, a Republican senator said the bill has “zero chance” to pass the Senate as is. Sen. Bob Corker, R-Tenn., said the sweeping health care passed Thursday would not pass quickly through the Senate without major adjustments. The New York Post reported that moderate senators are concerned about the bill’s Medicaid reductions. “The safest thing to say is there will be a Senate bill, but it will look at what the House has done and see how much of that we can incorporate in a product that works for us in reconciliation,” Sen. Roy Blunt, R-Mo., told The Washington Examiner. The revised American Health Care Act passed Thursday on a 217-213 vote. “We’re going to get this finished,” President Trump declared in a celebratory Rose Garden event, surrounded by Republican congressional allies shortly after the vote. He vowed premiums and deductibles will be “coming down” and the Affordable Care Act is “essentially dead.” The passage marked Republicans’ biggest step yet toward replacing the Obama administration’s signature domestic policy law. The bill heads next to the Senate, however, where it faces an uncertain fate. All Democrats voted against the bill on the House floor Thursday afternoon, warning it would jeopardize coverage; 20 Republicans voted no. Implying the GOP would lose seats in 2018, Democrats sang, “Na Na Hey Hey Kiss Him Goodbye” toward the end of the voting. But GOP leaders cheered the result. “Welcome to the beginning of the end of ObamaCare,” Vice President Pence said in the Rose Garden. Trump, praising House Speaker Paul Ryan, said he’s confident in Senate passage and predicted an “unbelievable victory.” Democrats, though, continue to rail against the legislation that would overhaul many key provisions of ObamaCare. Lawmakers took to the floor to call it a “gut punch to America,” and a boon for billionaires and “undertakers.” “This disastrous bill has been condemned by almost everyone,” House Minority Leader Nancy Pelosi, D-Calif., said Thursday at a press conference. She said the latest version is “worse” than the original and rejected claims it would protect those with pre-existing conditions. “This is a scar that they will carry,” Pelosi said of House Republicans who vote for the plan. Here’s a rundown of key provisions in the American Health Care Act and what would happen if the Senate approves them and the bill becomes law. Buying insurance The bill would no longer require people to buy insurance through the marketplaces created by the Affordable Care Act, also known as Obamacare, if they want to use federal tax credits to buy coverage. It also would eliminate the tax penalty for failing to have health insurance coverage, effectively doing away with that requirement altogether. In place of that mandate, the bill encourages people to maintain coverage by prohibiting insurance companies from cutting them off or charging more for pre-existing conditions as long as their insurance doesn’t lapse. If coverage is interrupted for more than 63 days, however, insurers can charge people a 30 percent penalty over their premium for one year. Tax credits The House Republican plan would eliminate the income-based tax credits and subsidies available under the Affordable Care Act, replacing them with age-based tax credits ranging from $2,000 a year for people in their 20s to $4,000 a year for those older than 60. That means some people will see their costs go up while others would pay less, depending on your age and where you live. This Kaiser Family Foundation interactive map shows how the change would play out across the country.
The map shows that a 27-year-old who makes $30,000 a year would see costs rise about $2,000 in Nebraska but fall by about the same amount in Washington state. A 60-year-old, however, would see costs rise almost everywhere, with increases of almost $20,000 a year in Nebraska. Both Kaiser and the Congressional Budget Office found that, on average, older people with lower incomes would be worse off under the Republican plan than under the Affordable Care Act. Tax cuts The bill eliminates nearly all the taxes that were included in the Affordable Care Act to pay for the subsidies that help people buy insurance. Those cuts, which add up to about $592 billion, include a tax on incomes over $200,000 (or $250,000 for a married couple); a tax on health insurers and a limit on how much insurance companies can deduct for executive pay; and a tax on medical-device manufacturers. Medicaid The AHCA would make dramatic changes to Medicaid, the federal-state health program for the poor and disabled. The Affordable Care Act allows states to expand eligibility for Medicaid to single, nondisabled adults with incomes slightly above the poverty line, with the federal government picking up most of the cost. That meant single adults who earn up to $15,800 a year could qualify in the 31 states, plus the District of Columbia, that expanded Medicaid. About 10 million people enrolled under that expansion. The Republican plan would gradually roll back that expansion starting in 2019 by cutting the federal reimbursement to states for anyone who leaves the Medicaid rolls. People often cycle in and out of the program as their income fluctuates, so the result would likely be an ever-dwindling number of people covered. The House bill also converts Medicaid from an entitlement program, in which the government pays all the health-related costs for those who qualify, to a grant program. The federal government would give states either a set amount of money for each Medicaid enrollee or let them choose to receive a fixed-dollar block grant. The Congressional Budget Office estimated in March that the bill would cut Medicaid spending by $880 billion. Pre-existing conditions The AHCA maintains protections for people with pre-existing conditions, with some important exceptions (see waivers, below). That means that someone with high medical expenses pays the same premium for the same policy as anyone else his age in his area. State waivers This section of the bill essentially amounts to an optional, state-level full repeal of Obamacare. It would give states the ability to apply for a waiver that lets them opt out of most of the regulations and consumer protections that were included in the Affordable Care Act. States could apply for waivers that would allow insurance companies in their states to do three things: 1. Charge older people more than five times what they charge young people for the same policy; 2. Eliminate required coverage, called essential health benefits, including maternity care, mental health and prescription drugs that were required under the Affordable Care Act; and 3. Charge more for or deny coverage to people who have pre-existing health conditions, such as cancer, diabetes or arthritis. The waivers could also impact people with employer-based insurance, because insurers could offer policies that have annual and lifetime benefit limits, which are banned under the Affordable Care Act, and some companies may choose those policies for their workers to lower premiums. States that get waivers would very likely see insurance companies offer many more policy options, some with fewer benefits and lower premiums. Those states would be required under the law to create some other way to ensure that people with expensive illnesses are able to get health care, and the law provides up to $138 billion over 10 years for such programs, typically called high-risk pools. However, an analysis released Thursday by consulting firm Avalere Health concludes that that amount would be inadequate for providing full health coverage for the number of people who now buy insurance in the individual market and have medical problems. Overall impact The House approved the bill Thursday without a full Congressional Budget Office analysis of its costs and how many people would be covered. The CBO report from March concluded that over 10 years, 24 million fewer people would be covered under the bill that otherwise would have had insurance under current law. That analysis also predicted that the House bill would cut federal deficits by $337 billion over those same 10 years. However, changes to the bill since then would allow states to accept block grants for Medicaid; add about $38 billion for high-risk pools and maternity and childbirth care; and offer states waivers from regulations created by the Affordable Care Act. It’s unclear how much these changes would affect the original CBO score. The Senate will review the House bill but will write its own version over the next few weeks, said Sen. Lamar Alexander, R-Tenn., chairman of the Health, Education, Labor and Pensions Committee. “We want to get it right,” Alexander said Thursday on the Senate floor. “There will be no artificial deadlines.” If the Senate passes its own bill, the House will either have to approve the Senate version or negotiate a compromise with senators, Alexander said. Any compromise bill would need to be approved by both the House and Senate before being sent to President Trump to sign. The New York Times in an article by Abelson, Thomas, reported that in “a rare unifying moment,” hospitals, physicians, health insurers, and some consumer groups are, “with one voice,” calling for “significant changes” to the health care bill that passed the House. Greenwood) reported in The Hill that the American Medical Association “blasted” House GOP lawmakers for passing the AHCA, and warned “the bill could turn back the clock on protections for patients with pre-existing conditions.” AMA President Andrew W. Gurman, MD, stated, “The bill passed by the House today will result in millions of Americans losing access to quality, affordable health insurance and those with pre-existing health conditions face the possibility of going back to the time when insurers could charge them premiums that made access to coverage out of the question.” He added, “The AMA urges the Senate and the Administration to work with physician, patient, hospital and other provider groups to craft bipartisan solutions so all American families can access affordable and meaningful coverage, while preserving the safety net for vulnerable populations.” After this week I am convinced that our Congress, or at least the House of Representatives, and that includes both parties are truly dysfunctional. Remember GOP, if this new health care act doesn’t improve the health care of our country, cover all of those subsidized patients out there, they will pay for it by losing their majority in both the House as well as the Senate, and NOTHING will get accomplished in the rest of President Trumps final years. My prediction is that as the months drag on and realistic minds take control, the new health care system will look more and more like a modified Obamacare. What do you all think?