Sunday, April 16, 2017

Trumpcase Updates

Like many issues that straddle both the US and Guam, there are ways in which their may be a shared, similar experience, but always ways in which geography, culture, identity, history and coloniality will make it different and distinct. For example, within a US context I may be on one side of any health care debate, but in Guam I may take a completely opposite position. Part of it depends on how I may see myself ideologically and politically in relation to issues of power, justice and progress in the US context. But when the discussion extends to the colonies, my sense of things tends to become more Guam and Chamorro focused. If Guam were a full part of the US, I might feel differently, but as it is not, I do not and should not assume that however things work in the US, is how they should work in Guam. Or that, like the colonial mantra goes, whatever is good for the US must be good for Guam. Because of this colonial difference, I haven't been following the Trumpcare debacle as much as I should. I spent the morning reading up on it.


Trump threatens to stop insurance payments to Democrats negotiate on Obamacare
by Lauren Fox
April 13, 2017

(CNN) - President Donald Trump is threatening not to reimburse health insurers for covering low income people as a way of forcing Democrats to the negotiating table on health care. 

In an interview with the Wall Street Journal published Wednesday, Trump said health care remained a top priority for him, but that he was still undecided about whether his administration would fund what are known as cost-sharing reduction payments, which reduce deductibles and co-payments for lower-income people.
Without the payments, insurers could try to pull out of the Obamacare marketplace immediately. Already, the uncertainty is prompting some insurers to drop out for 2018.
"I don't want people to get hurt," Trump said in the interview. "What I think should happen — and will happen — is the Democrats will start calling me and negotiating."
The payments were the subject of a House lawsuit under House Speaker John Boehner, which argued the Obama administration did not have the authority to make the payments without congressional approval. A district court judge last year sided with the Republicans and declared the subsidies illegal. The Obama administration appealed, and the lawsuit is still ongoing.
Trump was unclear about whether Congress might vote to authorize the payments, conceding only that as more time goes on, he does worry that his administration will be held responsible for any problems with Obamacare.
"That's part of the reason that I may go the other way" Trump said about paying the insurers. "The longer I'm behind this desk and you have Obamacare, the more I would own it."
Senate Minority Leader Chuck Schumer slammed Trump's comments, saying, "This cynical strategy will fail."
"President Trump is threatening to hold hostage health care for millions of Americans, many of whom voted for him, to achieve a political goal of repeal that would take health care away from millions more," the New York Democrat said in a statement. 
Some 7 million people, or 58%, of those who signed up for Obamacare coverage for 2017 qualify for these cost-sharing subsidies. 
In the same interview with the Wall Street Journal, Trump claimed his administration was "very, very close" on coming to an agreement with members of the conservative House Freedom Caucus on health care.
"They want to do the right thing," Trump said, referring to the conservative group. "They do like their president."
After Republican House leaders failed to pass a bill to repeal and replace the Affordable Care Act in the last congressional session, the White House is claiming it is taking a more active role in moving the negotiations along -- encouraging private talks between the Freedom Caucus and the moderate Tuesday Group.
But there is still no proof that Republicans are any closer to repealing Obamacare than they were six weeks ago. The effort appears to be little more than talks.
"Nothing major" is happening on the health care front aside from conversations, a GOP source very close to the negotiations told CNN.
According to a senior administration official, the White House believes there has been some progress on health care in recent days. But rather than take another stab at the very public lobbying and arm-twisting effort that the White House embraced twice and failed, this time the administration is keeping their private prodding out of the spotlight.
The White House official said they're largely leaving it up to the Freedom Caucus and the Tuesday Group to try to work out a plan that both sides can agree on with the White House quietly weighing in throughout the process.
During his news conference Tuesday, White House press secretary Sean Spicer told reporters that the administration was "getting closer and closer every day."
"More votes are moving in our direction," Spicer said. "And these ideas, I think, are very helpful and the conversations are getting closer."
Ever since Republican leaders were forced to pull their health care bill because there were not enough votes to pass it, the House Freedom Caucus has been very public about their attempts to negotiate with the White House. The conservative group took a large share of the blame for the legislation's failure the first time around even though there were several moderates who also refused to vote for the bill.
On Tuesday, a source with the House Freedom Caucus familiar with health care negotiations told CNN that caucus chairman Mark Meadows had been in discussions with both the White House and House Speaker Paul Ryan and had presented a plan to Ryan over the phone that would essentially allow states to wave certain regulatory requirements. It was unclear if the proposal had any support from moderates.
The fallout for the Freedom Caucus has been intense over the last month with Trump calling out leaders of the group -- including Meadows -- by name on Twitter. South Carolina Republican Rep. Mark Sanford told the Post and Courier last month that White House budget chief Mick Mulvaney, a former House Freedom Caucus member, delivered a message to him from Trump that Trump hoped Sanford voted against the health care bill so the President could support a primary challenger against him.
The White House has tried to down play tensions.
On Wednesday morning, Mulvaney appeared on CNN's "New Day" and argued the whole Freedom Caucus-White House showdown had been overblown by the media.
"That story got a little blown out of proportion," Mulvaney said. "It's been an interesting process. I went to go talk to the Freedom Caucus about health care a couple weeks back. They knew what the deal was. The deal was that I'm just on a different team right now. But it's good competition. It's a real collegial thing still."
The closer is now the loser.

President Donald Trump's plan to repeal Obamacare and overhaul the health system crashed into the ground on Friday as Speaker Paul Ryan pulled a bill shortly before a scheduled vote.

The two-month drama was the first test of Trump's ability to apply his business skills to the Congress, a historic graveyard for presidential priorities.
It didn't go well.

Trump, who ran as a self-proclaimed master negotiator and who White House Press Secretary Sean Spicer touted "the closer" in the final stages of the health care talks, bet everything on a power play Thursday night in which the White House dared members to either vote yes or keep Obamacare.
It was right out of "Art of the Deal," Trump's old business book in which he stressed the importance of being ready to walk away to force a sale.

But Republicans called his bluff. Some of them had studied the "Art of the Deal" themselves — Sen. Rand Paul (R-KY) handed out copies to Freedom Caucus members — and reached a similar conclusion.

"The person who enters the negotiation looking like they have to do the deal is in a disadvantage," Rep. Andy Harris (R-MD), a holdout from the House Freedom Caucus who read the book last week, told reporters on Friday.

Ryan and the White House gushed about Trump's unprecedented engagement, but the president found there were limits to schmoozing — even with members with close personal ties.

Rep. Dan Donovan (R-NY), the lone GOP member from Trump's hometown of New York City, told reporters he had been a personal friend of the president for two decades. But that didn't change his "laundry list" of complaints, from Medicaid cuts to tax credits that didn't go far enough.

Trump's limitations

The president's disinterest in policy and his refusal to guide the process until after a bill was nearly complete created unique problems.

On health care, Trump instinctively sided with the more moderate wing of his party, and arguably even more with Democrats.

He promised universal coverage, lower deductibles, zero cuts to Medicaid, Medicare, and Social Security, touted a Democratic plan to negotiate prices with drug companies, and even flirted with heretical ideas like Obamacare's individual mandate and single-payer healthcare in prior years.
But Trump was light on policy knowledge and his ideas only became less clear with time. During the campaign, he proposed achieving universal care through vague ideas like "deals with hospitals" or by allowing insurers to sell across state lines, a policy that was at best tangential to the overall health care debate.

This lack of basics left him reliant on others to carry out his vision. In his case, he drew from conservative ranks: Ryan, Health and Human Services Secretary Tom Price, and Office of Management and Budget Director Mick Mulvaney.
The marriage was an awkward fit for policy purposes. Trump had relied on conservative groups like the Heritage Foundation for advice throughout the campaign and his burn-it-down rhetoric often drew him closer to tea party politicians.

But his stated policy goals were still much closer to politicians like Sen. Susan Collins (R-ME) and Bill Cassidy (R-LA), who urged Trump to negotiate with Democrats and adopt their own bill that would allow states to keep Obamacare or adopt a system with universal catastrophic coverage.

Some in Trump's orbit noticed this dynamic and warned that trouble was brewing. Newsmax editor Chris Ruddy, a Trump confidant, argued he should ignore Ryan, dump conservatives, and establish a bipartisan commission to expand the safety net through Medicaid.

Even as Trump placed his trust in conservative advisers inclined toward smaller government, he kept promising better, cheaper health care that covered more people. If anything, his promises escalated, culminating in a pledge to provide "insurance for everybody" in a Washington Post interview. 
The combination left lawmakers more and more confused. A civil war was in the making and Trump offered few details as to which side he favored or how to resolve their differences.

He promised an imminent White House plan while House leaders worked on their own and it wasn't clear for weeks that they were ultimately the same thing. All the while, conservatives, moderates, and White House officials rushed to claim they were on the same page as the president.

This split was a major contrast with the way President Barack Obama led Democrats in passing the Affordable Care Act after over a year of near-death experiences.

The party had spent decades forging a consensus through failure after failure before the 2008 wave gave them the votes to try again. By then, they had negotiated buy-in from every wing of the party on a plan to expand private insurance through a regulated exchange with subsidies. There were major fights over whether to include a public option or how to handle coverage for abortion, but they never threatened the basic structure and goals they agreed to at the outset.

"We didn't struggle with health care because we're stupid, we struggled with it because it is an incredibly complex, massive challenge," Adam Jentleson, a former top aide to retired Senator Harry Reid, told NBC News. "They convinced themselves that we were just idiots and they would quickly take care of it."

The final push

Facing a divided party and unpredictable president, House Republicans finally settled on a plan with the White House to release a finished bill almost out of nowhere and pass it as fast as possible.
In doing so, they skipped the usual process of painstaking hearings, town halls, and negotiations that characterized Obamacare.

Within days, though, it became obvious the plan that tried to placate all sides left no one satisfied and many deeply upset. The party's goals were fundamentally different, not just their methods.

As for Trump? He didn't have much to say publicly, especially when it came to the specifics of the legislation and how it would help the average American.

Even in speeches promoting his plan, he told audiences he had considered letting Obamacare remain in place rather than handing Republicans ownership of health care. He said he was eager to move on to tax reform, but had to take care of health care first for procedural reasons. This made for an odd pivot when he warned conservatives in the home stretch that they would be wiped out in 2018 if they failed to support his bill.

This ambivalence, though, might explain why Trump sounded almost relieved on Friday to be back in his old comfortable position of dumping on Obamacare rather than slogging through the hard work of passing landmark legislation and then spending his presidency defending it.

"I think the losers are Nancy Pelosi and Chuck Schumer, because now they own Obamacare, they own it 100% own it," he said on Friday.
The Affordable Care Act overcame the tea party protests of 2009 and the Democrats losing their filibuster-proof Senate majority in 2010. It survived two challenges in front of the Supreme Court and the calamitous rollout of
Now it has withstood the attempt to replace it with the American Health Care Act, better known as Trumpcare.

Somehow, despite the intense political forces arrayed against it, and the mind-boggling policy problems it tries to solve, the 2010 health care law keeps defying efforts to wipe it out. That says something about the people who wrote it ― and what they have achieved.
Obamacare has never been hugely popular, and it has never worked as well as its architects hoped. Millions of Americans don’t like it and, even now, there are parts of the country where the markets are struggling to survive.

But the program has provided security and access to care for millions of others. More importantly, it has shifted the expectations of what government should do ― and of what a decent society looks like.
This week’s defeat of the Republican repeal effort shows just how hard it is to undo those changes. And it won’t get any easier.

What Obama And Pelosi Did (And Trump And Ryan Didn’t)

On Friday, hours before President Donald Trump and House Speaker Paul Ryan (R-Wis.) formally conceded their bill lacked the votes to pass, White House press secretary Sean Spicer signaled what was coming. Trump, he said, had “left everything on the field.”
The statement was preposterous
Trump and the Republicans in Congress had spent all of 63 days trying to pass their Obamacare repeal ― less than three weeks of which were spent actually debating the text of the AHCA. They held votes before Congressional Budget Office evaluations were ready, and were about to ask the full House to decide on the proposal just hours after making major changes to it. 
Over in the Senate, Majority Leader Mitch McConnell (R-Ky.) had already indicated he intended to bypass his committees altogether and take legislation directly to the floor ― perhaps with a quick House-Senate negotiation, a fast vote and a signature from the president.
By contrast, it took former President Barack Obama, former House Speaker Nancy Pelosi and former Senate Majority Leader Harry Reid (D-Nev.) more than a year to pass Obamacare ― a politically tortuous period that many people later blamed for Democrats losing their House majority in 2010.
At the time, every apparent error loomed large ― from taking on health care at all, to letting the process drag out for more than a year, to slavishly crafting a proposal as CBO specified, to cutting unpleasant deals with health care’s special interests.
Lost amid the recriminations was the talent each player brought to his or her task ― and the Democrats’ single-minded focus on avoiding mistakes of the past in order to achieve something their party had been trying to do since the days when Franklin Roosevelt was in the White House.

 The work had begun long before Obama even ran for president. In the aftermath of the defeat for Bill Clinton’s 1994 health care plan, activists, advocates and intellectuals regrouped ― and then spent literally years hashing out their ideas for achieving universal coverage in a politically viable way. When Obama did run, he borrowed their work for his own plan. When he was elected, the most pivotal committee chairman of the process, Senate Finance Chairman Max Baucus (D-Mont.), was ready with his own blueprint that looked nearly identical.

Baucus had done something else: Working with then-Sen. Ted Kennedy (D-Mass.), he had convened meetings with virtually every health care stakeholder, from hospitals to unions to insurers to patient advocacy groups, exchanging ideas and negotiating over principles. It meant that when the actual legislating started, the channels of communication were already open and the groundwork for a common vision was already in place.
And still it was a nearly impossible task. Like the Republicans this year, Democrats found consensus difficult to achieve ― among the outside groups, and within their own ranks as well. Liberals wanted a more generous program, and a public option. Moderates wanted to avoid too much government spending and too much meddling with the way independent businesses operate.
But unlike the Republicans, the Democrats’ reaction was to work with the different groups and slowly bring them along ― most vividly, by negotiating with a handful of moderate Republicans, in the hopes that one or two (or maybe more) would sign onto the plan. It never happened, but the effort to woo those members helped secure moderate Democrats who needed to tell their constituents that, yes, they had tried to be bipartisan.
One reason Democratic leaders were able to preserve legislative momentum was that they understood, at all times, where they were trying to go ― and they were fluent enough in the policy to handle direct negotiations on their own. One of the enduring images of Obama during the Affordable Care Act fight was his visit to a Republican Party policy retreat in Baltimore, where he fielded questions and parried criticisms from the assembled members for roughly 90 minutes.

Trump, by contrast, seemed to lack anything beyond a superficial understanding of the bill, to the point where allies worried about letting him negotiate details. “Either doesn’t know, doesn’t care or both,” a Capitol Hill aide told CNN about the president.
As for Pelosi, her job was easier than Ryan’s in one important sense. Nobody in her caucus was as extremist or nihilist as the Freedom Caucus, partly because Democrats had done so much prep work and hammered out a rough consensus before the hard legislating work began. 
But Pelosi didn’t try to jam through “slapdash” legislation, as Harold Pollack, writing in Politico, recently called the AHCA. And she didn’t flinch when her political task looked utterly hopeless.
When Kennedy’s seat went to Scott Brown, depriving Democrats of a filibuster-proof majority to approve a final compromise, she told Obama she would get the votes for the Senate’s bill ― and she did, taking charge of the whip count personally ― and working her caucus, one member at a time, until she had a majority.
On Sunday, during an appearance on CBS’s “Face The Nation,” Sen. Tom Cotton (R-Ark.), conceded that maybe the Democrats knew what they were doing.
“When the Democrats came to power in 2009, for 60 years at least, they had been pursuing a national health care system, yet they didn’t introduce legislation for eight months, and they didn’t pass it for over a year of Barack Obama’s first term,” Cotton said. 
“I am not saying we needed 14 months to do this,” he added, “but I think a more careful and deliberate approach, which we now have time to do because we are going to have to revisit health care anyway, would have gotten us further down the path to a solution.”

The Resilience Of Obamacare

But the Republican failure wasn’t just about process. It was also about policy ― and a failure to realize just how profoundly the Affordable Care Act has changed public expectations for how the U.S. health care system operates.
The end product of that long, cantankerous debate in 2009 and 2010 wasn’t pretty. Keeping the health care industry on board meant heeding their demands to ratchet back aggressive cost controls. Holding moderate Democrats in the coalition meant putting a tighter lid on what the program would spend. Passing the Senate bill meant accepting statutory language that its authors had hoped a conference committee would clean up before enactment.
These compromises and concessions made implementation difficult. The sloppy language from the Senate bill exposed the program to the lawsuit King v. Burwell, which, if successful, would have destroyed the exchanges. The deals to secure support from individual members, like the “cornhusker kickback” that helped reel in Sen. Ben Nelson (D-Neb.), stained the whole effort with a tinge of corruption. The stingy funding meant that some middle-class people wouldn’t get much financial help, despite high premiums.
Republicans proved exceptionally adept at turning these problems into political advantages. But more frequently than not, they attacked the law because it wasn’t living up to liberal ideals ― because it left middle-class people on the hook for premiums, or because the plans had onerous deductibles, or because it was insufficiently harsh to the health care industry. McConnell was fond of pointing out that the law had left some 25 million people uninsured.
The message was unmistakable: The health care law had failed because it had made health care harder for people to get, and the GOP had a better way.
These arguments helped Republicans grab and hold congressional majorities, and they helped put Trump in the White House. But McConnell wasn’t interested in covering more people any more than Ryan wanted to lower people’s deductibles. And the need to write legislation exposed their real policy preferences ― which were lower taxes, fewer regulations and less government spending on the poor.
The combination meant that more people, not fewer, would be exposed to crippling medical bills. When the CBO finally did weigh in, the number of people predicted to lose their insurance, 24 million, was so big that even Republicans couldn’t spin or lie their way out of it.
“All politicians overpromise,” Jonathan Chait, of New York magazine, observed. “But the Republicans did more than overpromise. They delivered a policy directionally opposed to their promises.”
Republicans had also convinced themselves that nobody who had insurance through the Affordable Care Act liked it. The media coverage made it easy to believe this. Stories of people losing their old plans or paying more for new ones were all over the press for the first few years of the program. Stories of people saving money, or getting insurance for the first time, were much harder to find. 

But as surveys showed, the majority of people getting coverage through the Affordable Care Act were actually satisfied with it ― and quite a few were deeply grateful. In the last few months, finally, their stories became part of the conversation. They showed up on television, in the print media, and especially at town hall meetings ― forcing Republicans to answer questions they’d successfully dodged for years by tapping into anger with “Obama” and glossing over details about the “care.”
“If it wasn’t for Obamacare, we wouldn’t be able to afford insurance,” an Iowa farmer told Sen. Chuck Grassley (R-Iowa). Recalling Grassley’s 2009 false warning that the Affordable Care Act had “death panels,” the farmer said, “With all due respect, sir, you’re the man that talked about the death panel. We’re going to create one big death panel in this country if people can’t afford insurance.”
At a CNN town hall, in front of a live national audience, an Arizona man with cancer told Ryan that the health care law was paying for his cancer treatment. “I want to thank President Obama from the bottom of my heart because I would be dead if it weren’t for him,” the man said, adding that he was a Republican who once opposed the law and had volunteered in GOP campaigns.
The backlash left Republicans visibly rattled. And although leaders tried to write off such incidents as paid activists making trouble, they couldn’t explain why nearly every group connected to health care ― from the American Medical Association to AARP ― was making the same arguments.
Nor could Republicans explain plummeting public support for the legislation. By the end, the GOP bill had support from just 17 percent of the population ― much less than Obamacare, at its worst, ever polled.
Up until the end, Republicans had the votes to pass the House bill or something like it, and deliver Trump the big win he craved. It’s not so difficult to imagine a scenario with slightly better leadership, and slightly less obstreperous Republican factions, in which the legislation would have gone through both chambers and eventually to the White House.
But doing so would have almost surely produced a massive political backlash, because taking health insurance away from millions of people ― depriving people of health care because they have a pre-existing condition, or because they don’t have enough money to pay for it ― is no longer acceptable. 
It was the status quo until 2010. That was seven years ago and there is very little enthusiasm for going back.
As Sen. Bill Cassidy, a conservative doctor who represents the conservative state of Louisiana, told The New York Times, “There’s a widespread recognition that the federal government, Congress, has created the right for every American to have health care.”

What Happens Now

Obamacare remains a shaky enterprise, with markets in several states down to two or even one insurance company. And Trump, who has already taken some actions to sabotage the program’s performance, might make it even a shakier.
“Bad things are going to happen to Obamacare,” Trump said from the Oval Office on Friday, making what sounded to a lot of people like a threat. “There’s not much you can do to help it.”
Nobody questions that Obamacare requires reinforcement and repair ― or that someday it might need total replacement. Conservatives and liberals each have plenty of ideas along those lines. 
But the standard for judging any of these proposals, or some bipartisan combination of them, will be the same one that Trumpcare failed to meet: Does it protect the people who need protection? Does it improve access to care? Does it reduce financial insecurity? Does it move the U.S. closer to a system where all Americans truly have a way to get the medical care they need ― at a price they can afford?
This, in the end, is what Obama, Pelosi and their allies achieved with the Affordable Care Act ― not the creation of a jury-rigged system of regulations and tax credits, or the expansion of an overtaxed Medicaid program, or any of the myriad smaller policy initiatives the Affordable Care Act. The true legacy of Obamacare is the principle that everybody should have health insurance. 
Erasing that is not something that can happen in 63 days. And it may never happen at all.


 What Wasn't Trumpcare More Popular?
by Olga Khazan
April 14, 2017
The Atlantic

Spring is a time for rebirth, and at least for some Republican leaders, that goes for health-care legislation, too. Talks have reportedly resumed on reviving a version of the Republicans’ Obamacare alternative, the American Health Care Act, as my colleague Russell Berman reports, even as House Speaker Paul Ryan called Obamacare the “law of the land” just a few weeks ago.

The bare bones of the AHCA will likely form the basis of whatever the party does next on health care, according to two Republican Capitol Hill aides. That might be concerning to the various physician, hospital, and insurance groups who opposed the bill, not to mention the many conservative, centrist, and liberal health-policy wonks who reviled it. (One of the staffers said outside groups simply misunderstood “what our bill did and did not do.”)

The AHCA’s epic failure, and potential resurrection, makes it worth asking—why has it been so difficult for Republicans to come up with something that’s at least more popular than the IRS? (To name just one example, Politico magazine, a publication not exactly known for partisan snark, called the bill “a Dumpster fire.”) And will anything be different if Republicans try their hand at health-care reform again?

I spoke with half a dozen conservative-leaning health-policy experts for their take on why Republicans didn’t have something better than the AHCA ready. Four broad theories emerged:

Republicans just didn’t give themselves enough time

A decade ago, the Democrats also had conflicting health-care ideas, squabbling over single-payer and a public option, but they worked it out in legislation, says Dan Holler, the vice president of communications for Heritage Action for America. “That’s not something that was capable of happening in 17 days” for Republicans, he said. The rush to pass the AHCA “was a misread of where the [Republican] conference was.”

James Capretta, with the American Enterprise Institute, said outside groups—he implicated Heritage Action and Club for Growth—were urging Republicans to repeal Obamacare as quickly as possible. Because of that, House Republicans “didn’t give themselves enough time to ... develop [Paul Ryan’s plan] ‘Better Way’ into a more politically viable replacement plan.”

Perhaps it would have become more palatable if they had spent nine months on it, as the Democrats did on Obamacare.

It wasn’t clear what the goal was

“Repeal and replace” seemingly meant different things to different Republicans. Moderates wanted to protect the law’s more popular provisions while tweaking its subsidy structure. The House Freedom Caucus thought Obamacare should be uprooted entirely. It’s hard to write a bill that simultaneously bolsters and destroys a federal program.
John Goodman, with the Independent Institute, believes the AHCA was authored in a way such that it would cut federal spending—the goal of conservative Republicans—not necessarily boost health-care coverage. The comparatively lower health-insurance enrollment levels under the AHCA were a feature, not a flaw, in other words. “If 24 million people don’t get health insurance, 24 million people won’t be getting subsidies through Medicaid or through the tax credits,” Goodman wrote in Forbes recently. “That means less spending.”

There are only so many ways to do health-care reform

Some nicknamed the AHCA “Obamacare lite,” and it does, indeed, have lots in common with the Democrats’ law. But it was also similar to past GOP proposals, like Health and Human Services Secretary Tom Price’s “Empowering Patients First” plan, as well as the plan offered up by Jeb Bush on the campaign trail. In fact, a 1989 plan from the Heritage Foundation—the one that started it all—also included tax credits and an individual mandate.

“Every time I put Obamacare in my search engine, someone has a snarky headline: ‘Republicans are starting to like Obamacare,’” said Bob Laszewski, an insurance-industry analyst. “The original outline was their idea!”

That’s because there are two basic models for health systems, Laszewski says: single-payer or Obama/Ryan/Trump/Heritage/PriceCare. One is a government-run system offers a rudimentary plan to everyone. The other one is a delicate Jenga tower of mandates, credits, and incentives, all balanced on the rickety table of the private-insurance industry.

Republicans had to go with the AHCA, that is, because there just aren’t that many other, non-socialist ways to do health insurance coverage.

And why did it take them so long—seven long years of the Obama administration—to come up with this particular formulation? Laszewski reminded me that the Democrats also hemmed and hawed for years over health care—decades, if you include the Hillarycare debacle of the early ’90s. Ultimately they settled on Obamacare, helping the poor at the expense of the better-off, while the AHCA would have done the opposite.

In other words, “when the Democrats had their shot, they took care of their base,” Laszewski said. And the Republicans took care of theirs.

Republicans just aren’t into health-care policy

Most politicians’ knowledge of the issues is “miles wide but less than an inch deep,” says Michael Cannon, the director of health policy studies at the Cato Institute. When it comes to many Republican policymakers and health care, though, that depth might be closer to a centimeter.

The reason? Republicans tend to like limited government, and health-care legislation is, well, governmenty. Sure, you could de-regulate health care to reform it, but usually new health laws result in the federal government telling doctors, insurers, or states to do something. That just isn’t the GOP’s thing!

“When Republicans have tried to apply their limited-government philosophy to health care, they’ve been beaten over the head by Democrats who say you’re trying to take away access to care,” Cannon said. “They’ve decided, ‘I don’t want to get hit on the nose with a crowbar anymore. I’m going to focus on other issues.’”

But their disinterest hurts them even more, Cannon says. Moderates in the House fear being pilloried at town halls and in ads for voting for a law that might make medical care more expensive. But Cannon feels they haven’t put much effort into explaining what they think is wrong with Obamacare’s more popular provisions, like the ban on excluding people with pre-existing conditions. “They just haven’t done their homework,” Cannon said.

“We used to say Republicans didn’t have the health-care gene,” added Merrill Matthews, a resident scholar with the Institute for Policy Innovation. “It just was not their issue.”

Now that health care is the Republicans’ problem, though, maybe it will become their issue, as well.

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