Why did the Graham-Cassidy Bill Fail and What are the Challenges Going Forward?

corner116So, the GOP has again failed to pass their own health care bill, which was supposed to Repeal and Replace the Affordable Care Act. Why? Charles Pierce a writer for Esquire wrote a great review as to why they failed. With every Senate Democrat opposed to the bill, the publicly announced opposition of three Senate Republicans – Rand Paul (KY), John McCain (AZ), and Susan Collins (ME) – was enough to ensure it was headed for defeat. So rather than force vulnerable senators to take another politically damaging vote certain to end in failure, McConnell has decided not to hold the vote at all. “We don’t have the votes,” Sen. Bill Cassidy (R-LA), a co-author of the bill, said at a press conference Tuesday. “And since we don’t have the votes, we will postpone that vote.”

Sen. Lindsey Graham (R-SC), the other co-author, was publicly optimistic and asserted that his bill would pass eventually. “We’re coming back to this after taxes,” he said. But the cancellation of this week’s vote has major implications. That’s because on Saturday, September 30, Congress’s current “budget reconciliation” instructions, which set up the special process that lets the Senate advance a bill with a simple majority rather than 60 votes, are set to expire.

This is more than simply splashing another rickety aircraft that never took off. In one bill, almost the entire ideological superstructure of modern Republican conservative social policy came apart at the seams. The Graham-Cassidy bill was a dog’s breakfast of misbegotten assumptions and Tenth Amendment wet dreams, all the things that have driven Republican domestic policy since Ronald Reagan descended upon the Capitol. It evinced no more familiarity with how most Americans experience the healthcare system than it did with the proceedings of the Romanian parliament. In fact, it evinced a very little familiarity with human beings at all, so much so that even Republican governors ran screaming from it, refusing to take part in a catastrophic suicide mission just because the president* needed a win.

The bill’s prospects worsened by the day, and Monday was the worst day of all. First, there was the Senate hearing marked by a video of protesters in wheelchairs being hauled off by Capitol cops. Then, there was the announcement by Senator Susan Collins that she was the third (and final) no vote. The CBO chimed in with a partial score that was as horrific as all the others have been. Then, the unexpectedly formidable tag team of Amy Klobuchar and Bernie Sanders had Graham and Cassidy for after-dinner mints on CNN. The fact is that this bill never should have been written, never should have gotten out of committee, and certainly never come this close to final passage.

The entire ideological superstructure of modern Republican conservative social policy came apart.

(Among other things, this episode has left in ruins the credibility of Cassidy, a heretofore-obscure Louisiana senator and, god help us, a physician himself. His prevarication on behalf of the bill got so frenzied as the time for a decision came closer that, if things had gone on another two days, Cassidy likely would have said that his bill would raise the dead through the “power of the free market.”)

And to add to their problems Tom Price, MD, the orthopedic surgeon from Georgia who rose to national prominence as a fiscally conservative congressman and was an early supporter of President Trump, resigned Friday from his position as Health and Human Services Secretary.

An ardent opponent of the Affordable Care Act and outspoken champion of physician autonomy, Price came under fire in recent days for his use of private charter jets as well as military aircraft for travel, sometimes to destinations as far-flung as China, but also for trips as short as jaunts from Washington to Philadelphia.

Yesterday Price apologized for his travel decisions and said he would repay the government for his “seat” on charters, a sum that totaled just over $50,000 but fell well short of the tens of thousands in charter fees for jets with 20 or more seats. Politico, which broke the private jet scandal, put the total cost for charters and military planes Price had used at more than $1 million. Earlier Friday, Trump was equivocal when asked if Price’s job was in jeopardy.

During his brief tenure at HHS, Price moved rapidly to undo many Obama-era regulations and in his budget proposal suggested significant cuts to the CDC and NIH.

Alas, as should be obvious, this isn’t the last round that we will go on this, at least if and until the Democrats achieve some sort of congressional majority. But the bad faith that surrounded this attempt was so noxious and thick that it makes me dubious of any “bipartisan” plan to fix the ACA that includes any senator beholden to Mitch McConnell. This is probably unfair, but when you see McConnell personally kill an ongoing bipartisan effort – the so-called Alexander-Murray plan – and then blame “the Democrats” for its demise, it’s really hard to accept that he’s going to do anything short of sabotaging any attempt to leave any part of the ACA intact.

The simple fact is that the ACA places in the federal government powers that most Republicans do not believe it should have, and that it helps people that most Republican believe do not deserve help, either through their own sloth, or through some inscrutable divine selection to be found between the lines of the Book of Deuteronomy. That will not change. They will be back on this – probably after they bungle their attempts to “reform” the tax code so as to shove more of the country’s wealth upwards. And if you think their calculations at the moment don’t include John McCain’s death and Robert Menendez’s criminal trial, you’re fooling yourself. This is politics at its most elemental, dealing with the most elemental thing in every human life – good health.

Cassidy likely would have said his bill would raise the dead through the “power of the free market.”

But, for now, all they have left for an alibi is that they “promised” their voters that they would rid those voters of the shackles imposed by the ACA. They are still imprisoned by their fears, perhaps not entirely unfounded, of their party’s enraged base. There will be continuing sabotage at the state level and more hysterical headlines, and there ever will be lies and an endless parade of straw men. The fact is, however, that any strategy that involves exhausting the opposition seems doomed to fail. You spend decades building a party on the presumption that government is wrong and then fate gives you a chance to run the thing, and you run it over your own feet because that’s what you’ve set yourself up to do.

As Rick Newman pointed out the Republicans continue to bomb on health care! Why?? If the Republicans in Congress want to try again to pass a health care bill, maybe they should make it about health care.

Three Republican efforts to repeal the Affordable Care Act failed spectacularly this year — including the latest, the Cassidy-Graham bill — because they weren’t really about health care. They were about money. Sure, the two are inextricably linked, but if your goal is to slash federal spending so you can cut taxes, then label your bill the Great American Tax Cut Act and promote it that way. Apparently, there are enough smart voters to tell it’s a sham when you label something a “health care” bill but what you really do is eliminate care in order to save money.

Democrats made one giant mistake when they passed the Affordable Care Act, aka Obamacare, in 2010: They hurt some people in order to help others. The law helped millions of low-income Americans who couldn’t otherwise afford health insurance get it. But Obamacare punished middle-income Americans — especially those between the age of 50 and 64 — who bought individual policies and earned too much to qualify for subsidies under the ACA. Their premiums skyrocketed and some had their plans canceled because they didn’t comply with new ACA rules. President Barack Obama earned the Politifact Lie of the Year award in 2013 for his claim that “if you like your health care plan, you can keep it.”

The competition for future Lies of the Year would have been intense had any one of the three GOP health care bills passed this year. Their backers claimed the bills would push health care costs down, improve coverage for people covered under Obamacare today and create more efficiency. But the main goal of each bill was to drastically cut federal spending on Medicaid, the health program for the poor. Obamacare expanded Medicaid, and the GOP scheme was to roll back that expansion and go further.

Under each of the three bills, the number of uninsured would have soared, with estimates ranging from 22 million to 32 million addition people lacking coverage during the next decade. By definition, that is not health care reform.

What have we learned for Obamacare? The lesson of Obamacare was the old medical oath: First, do no harm. So if the GOP ever produces an actual health care bill, its first aim should be to keep coverage levels where they are, at a minimum. Its second aim should be lowering costs for everybody, including those covered by government plans and those covered by private-sector plans. Getting costs under control would by its very nature help more people afford health care coverage, and lessen the burden on taxpayers who support Medicaid and other federal health programs.

Tackling the chronic rise of medical costs in the United States won’t be easy, but it’s not impossible, either, and plenty of smart reformers have ideas. The government could come up with new ways to incentivize private-sector providers to lower costs, giving the free market a nudge to do what it’s best at. Providers should be rewarded, for instance, for offering the best care at the lowest price instead of offering the most care, regardless of the outcome. This requires much better ways of measuring quality and long-term results. But isn’t this the kind of thing Silicon Valley is supposed to excel at? Isn’t artificial intelligence about to provide the ability to do remarkable new things? Isn’t there an app for that?

Now What? What are the 5 Looming Challenges For The Affordable Care Act Now that the GOP has failed to Repeal and Replace Obamacare

Julie Rovner reviewed the looming challenges for the Affordable Care Act as the GOP has failed once again the Repeal and Replace. Republicans officially pulled the plug on their last-ditch effort to repeal and replace the Affordable Care Act on Tuesday.

“We don’t have the votes,” said Sen. Bill Cassidy, R-La., after a closed-door meeting of Senate Republicans. “And since we don’t have the votes, we’ve made the decision to postpone the vote.” Cassidy, along with Sen. Lindsey Graham, R-S.C., put together the proposal they hoped could pass the Senate.

As of Sunday, though, the Senate will no longer be able to pass a health law overhaul bill with only a simple majority. That means the bill is effectively dead, for now.

Senate Majority Leader Mitch McConnell, R-Ky., underscored that message who said, “Where we go from here is tax reform.”

But that does not mean all is smooth sailing for the ACA. Here are five ongoing challenges the law faces.

  1. Insurers still face tremendous uncertainty.

Wednesday is the deadline for health insurers to finalize rates for the 2018 individual market open enrollment season, which starts Nov. 1. Yet there has been no resolution to the question of whether the federal government will continue to reimburse insurers for subsidies known as cost-sharing reductions. Those are payments insurers are required to provide to moderate-income enrollees to help them afford deductibles and out-of-pocket costs. The law says the federal government is supposed to make those payments, but a lawsuit has left that an open question and the Trump administration has repeatedly threatened to stop making the payments.

Without reimbursement of those subsidies, Pennsylvania Health and Human Services Secretary Teresa Miller told the Senate Finance Committee Monday, insurers in her state “reported they would need to request a statewide average increase of 20.3 percent” in the cost of health plan premiums. Those increases are similar nationwide.

A bipartisan effort led by Senate Health, Education, Labor, and Pensions Committee Chairman Lamar Alexander, R-Tenn., and Patty Murray, D-Wash., to advance legislation to affirmatively fund the payments were reportedly progressing until Republican leaders stopped them to concentrate on efforts to pass the Graham-Cassidy legislation.

But Alexander and Murray now appear back at it. Murray said Tuesday she is “ready to keep working on the bipartisan path that could lead to results.”

Alexander similarly released a statement that he would “consult” with Murray and others “on a limited bipartisan plan that could be enacted into law to help lower premiums and make insurance available to the 18 million Americans in the individual market in 2018 and 2019.”

  1. The Trump administration has cut funding for efforts to sign people up for insurance.

Administration officials announced earlier this month major cuts to the “navigator” program, which provides funding to community groups that guide people through the complex task of signing up for health insurance through the online marketplaces. Some groups are losing more than 90 percent of their budgets.

The cuts have forced many groups to lay off workers just before open enrollment begins and to limit the areas they serve.

  1. The 2018 enrollment period is half the length of 2017’s, and now it will be shorter still.

Trump officials are also slashing by 90 percent the advertising budget that reminds people about open enrollment and how to sign up — from $100 million to $10 million.

Those cuts are even more significant this year because, for the first time since the law’s implementation, open enrollment starts in November, rather than December, and lasts only 45 days.

“Most people don’t know the open enrollment dates, and they don’t know that the deadline this year is Dec. 15, not Jan. 31, like last year,” wrote Lori Lodes, who ran outreach for the ACA in the Obama administration, in a recent op-ed for Vox.

Trump administration officials said they don’t think advertising is cost-effective, but Lodes wrote: “my office produced reams of data that proved the overall effectiveness of outreach advertising.”

Additionally, HHS announced late last week that it will shut down HealthCare.gov for maintenance from 12 a.m. to 12 p.m. every Sunday during open enrollment, except for Dec. 10 – a step critics say could further undermine enrollment efforts.

4. The Trump administration is dragging its feet on giving states flexibility to stabilize their markets. Back in March, Health and Human Services Secretary Tom Price and Centers for Medicare & Medicaid Services chief Seema Verma, who oversees the ACA, sent a letter to states encouraging them to use the law’s waiver process to improve the functioning of their individual insurance markets. In particular, they suggested states could create “reinsurance” programs that would help lower premiums by providing a payment mechanism for the most expensive patients.

But when Minnesota took up that invitation, the administration delayed its response. When it finally did grant permission last week, HHS also informed the state that it will lose significant funding for a program that provides insurance to the state’s low-income residents.

Gov. Mark Dayton, a former Democratic senator, said in a letter to Price that “we have now been informed that Minnesota would lose more federal Basic Health Plan funding than we would receive in federal support for reinsurance,” and described the entire waiver process as “nightmarish.”

  1. Republicans could take another shot at a full overhaul next year — or even this year.

While the acknowledgment that the GOP lacks the votes to overhaul the health law means an immediate vote will not happen, the Republicans have potentially two more shots to try to pass a bill with a simple majority vote.

What triggers the ability to pass a bill in the Senate without the threat of a filibuster is a formal budget resolution. Republicans have still not passed a budget resolution for fiscal 2018, which begins Oct. 1. The upcoming resolution is expected to call for a major tax cut bill. Some Republicans, notably Graham himself, have suggested adding health language to that resolution, which would be allowed.

But that would complicate efforts for both bills.

More likely is that Republicans could try again for a health overhaul via its fiscal 2019 budget resolution, which is due next April. That would leave them only a few months before the 2018 elections. Still, it’s possible, particularly if they can use the time to reach consensus.

That is clearly what sponsors of the latest GOP bill have in mind.

“We’re on a path to pass” his bill, Graham told reporters. “It’s just a matter of when. It will be in this Congress, under a better process.”

It is predicted that In 47 of 50 cities, ObamaCare insurance coverage will be ‘unaffordable’ in 2018 by law’s definition

Ali Meyer of the Washington Free Beacon pointed out the in 47 of 50 cities in 2018, the cost of Obamacare’s lowest-priced plan would be deemed “unaffordable” by the Affordable Care Act’s own definition, according to a study from eHealth, Inc.

Under the Affordable Care Act, health insurance becomes unaffordable when the lowest-cost plan costs more than 8.16 percent of a household’s gross income. Usually, people who fall in this category can get an exemption from paying Obamacare’s individual mandate.

“Government subsidies are available to people earning up to 400 percent of the federal poverty level, but middle-income households earning 401 percent or more of the federal poverty level are not eligible for subsidy assistance,” eHealth explains.

The study evaluated families with two adults and one child in 50 cities who were paying the lowest-price plan in 2017. The study then applied a 10 percent increase to premiums to project the rates seen in 2018 and found that in 47 of those cities, coverage would be unaffordable. The increase that the study projected was moderate since many have estimated that premiums could increase by as much as 20 percent next year.

In addition, these families would need to incur an extra $28,939 before the plan became affordable. On average, a family of three would have to earn a six-figure salary—or $110,823.32—for coverage to be affordable.

My thought, as I write my next book on the history of health care reform, is that the United States also ought to be moving toward universal health care coverage, which would have economic benefits and is the modern standard in every other advanced nation. Universal coverage doesn’t mean a single-payer system dominated by the government, which frankly doesn’t seem plausible in the United States anytime soon. Instead, we could get there by relying more or less on the system we have now — including employer-provided care — while instituting some kind of new government backstop as last-resort catastrophic care for the unfortunates who still lack coverage. No less a conservative stalwart than economist Milton Friedman proposed this in 2001.

Meanwhile, stabilizing the Affordable Care Act would be the responsible thing to do, until Congress comes up with something that is legitimately better. That means enforcing all provisions of the law, committing to all the funding mechanisms and promoting it thoroughly so people know how to sign up. The ACA is far from perfect, but if Republicans abandoned their white-whale obsession with killing it, they could pursue other reforms that would actually help people, and businesses.

Finally, if Republicans are intent on reeling in Medicaid, they should pursue that on its face. Medicaid spending is, in fact, on an unsustainable trajectory, just like Medicare and Social Security. It’s inevitable that at some point, Congress will either have to cut funding for these entitlement programs or raise taxes to pay for all the benefits that have been promised. So addressing Medicaid spending isn’t inherently evil.

The problem is doing it sneakily, which is what the Republicans have been doing all year, by dressing up sharp Medicaid cuts as the “Better Care Reconciliation Act” and other nonsense. If you want to cut Medicaid, guys? Then call it what it is. Meanwhile, it would be nice if you could think about fixing the healthcare problems we still have, at some point. And more importantly, use all avenues to evaluate the options and strategies and work together with the Democrats to solve the problems and act like responsible grown-up big boys and girls.

Finally, the book that my co-author and I have been working so hard on is in the publisher’s hands and now, as I previously mentioned, I am working on the second chapter of the new book on health care reform. This chapter will focus on the question-Health Care a right or a privilege?

 

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