Obamacare v. Trumpcare

Some recent updates on the health care debate in the United States. It is fascinating to contemplate that in the past few years one party lost political power in order to expand health care to tens of millions of more people, and now another party is on the verge of potentially losing power as well, by taking health care away from tens of millions as well.

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"Americans decided that health care is for all. Republicans want to roll that back."
Former Vice President Joe Biden
Washington Post
July 17, 2017

As vice president, I met with Americans all across our country. What they told me over and over is that the Affordable Care Act gave them peace of mind — that if they got sick, or if their child got sick, they could get care and not have to worry about going broke as a result. They no longer had to lay awake at night wondering: Can I pay for this treatment? What happens if she gets cancer? How will I feed my family and afford the care?

They told me that because when the ACA became law and health-care coverage was extended to millions of people, it meant we had finally decided, as a nation, that health care is a right for all and not a privilege for the few.

Republican leaders in Congress believe the opposite. And if they take that peace of mind away, they’ll have to look Americans in the eye and explain to them that they have to start worrying again.
Last week, Vice President Pence told the National Governors Association that the GOP health-care bill currently being debated in the Senate “strengthens and secures Medicaid for the neediest in our society.” Respectfully, that’s simply not the case. Their bill tries to deal with opioid addiction on the cheap, eviscerates the ACA’s Medicaid expansion and guts the ACA’s promise that care like maternity and mental health and substance-use disorder services must be part of any viable health coverage system. They want to drag us back to a time — not all that long ago — when Americans could be denied basic health care because they were unable to afford it. That’s the reality of where we are today and it’s enough to make your blood boil.

Now, I hear some folks say: But hospitals don’t turn anyone away from the emergency room. Before the Affordable Care Act, though, hospitals provided about $40 billion each year in uncompensated care. People who didn’t have health insurance or couldn’t cover their co-pays were putting off needed medical care and skipping out on preventive care altogether. That’s not a sustainable model, and we’re better than that. A health-care system built around emergency room visits isn’t a health-care system at all.

The ACA isn’t perfect, but the choices we made when designing the law flowed from a commitment to provide the best possible care to the most people. Compare that to Republican proposals, which the nonpartisan Congressional Budget Office has said will mean more than 20 million fewer people will have health coverage by 2026, and millions more will no longer have the same protections provided by the ACA.

Here are just some of the people who could lose access to care if congressional Republicans get their way:

More than 70 million Americans rely on Medicaid, including close to 2 million veterans. Medicaid, including the Children’s Health Insurance Program, covers 39 percent of children in America, 49 percent of all births, 35 percent of Americans with disabilities and 64 percent of nursing home residents, around seven in ten of whom are women. Rural hospitals would be hit especially hard by proposed cuts because they’ve benefitted most from the Medicaid expansion that has meant fewer uninsured requiring uncompensated care, and yet Senate Republican leadership is looking to cut Medicaid by about three-quarters of a trillion dollars.

Slashing the Medicaid expansion would affect over a million Americans who’ve used it to cover mental health and substance-use disorder treatment. The original Senate bill proposed spending $2 billion to address the opioid epidemic — a drop in the bucket when it comes to addressing a crisis that is ravaging communities and ripping the heart out of our country.

After facing an outcry, Senate Majority Leader Mitch McConnell increased that to $45 billion. But my longtime Senate colleague is, I believe, missing the point. You can’t take away comprehensive health insurance from people struggling with opioid addiction and then just throw $2 billion or, for that matter, $45 billion their way for treatment. Experts say we need closer to $183 billion over 10 years to provide those on Medicaid with treatment for addiction and to provide care for other illnesses that often affect those addicted to opioids. Americans in communities affected by this epidemic understand firsthand that the status quo is grossly inadequate. We must do more to address this crisis, not less.

A middle-class family getting health insurance through a small employer could lose coverage for maternity care, mental health care or substance-use disorder services. Under the Senate’s bill, they would bear the burden of paying for these services out-of-pocket or having to go without them.
The new bill would create two individual insurance markets: One in which insurers must cover people with preexisting conditions, and one in which they don’t. And you don’t need a Ph.D. in economics to guess what would happen next: Healthier, younger people would flock to the less expensive, unregulated market. Those remaining in the regulated market will be older and sicker, and their premiums would increase to the point that they could be left with an option for insurance that exists on paper, but not in practice.

If you’re young and healthy, maybe this bill means that you’d pay lower premiums. But the thing about life is that if you’re lucky, eventually you grow old, and, in the meantime, you don’t know what will happen next. In the blink of an eye, or in one phone call from a doctor, your outlook may change. And if, God forbid, you find yourself in that position one day, I hope we still have the ACA in place so you can have the peace of mind that comes with knowing that no matter what, you can still get affordable care.

Senator McConnell says there’s still time to make changes to the bill before it gets to the Senate floor. But it shouldn’t even get there, because his bill can’t be fixed. By denying that all Americans have a right to health care, it’s fundamentally flawed. And Republicans are underestimating the American people if they think a few changes to the bill here or there will convince us that this bill is anything but a big step backward.

In my 36 years as a senator, I saw my colleagues take plenty of hard votes. This just isn’t one of them. If Republican leadership wants to improve the ACA, let’s first come to an agreement that everyone should have health coverage. Then, based on that premise, let’s have a debate about how best to improve care and reduce costs. Let’s again make the commitment that in America, health care is a right for all, not a privilege for the wealthy.

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 "Republicans Leap into the Awful Known"
by Paul Krugman
New York Times
July 17, 2017

Sometime in the next few days the Congressional Budget Office will release its analysis of the latest version of the Republican health care plan. Senator Mitch McConnell is doing all he can to prevent a full assessment, for example by trying to keep the C.B.O. from scoring the Cruz provision, which would let insurers discriminate against people with pre-existing conditions. Nonetheless, everyone expects a grim prognosis.

As a result, White House aides are already attacking the C.B.O.’s credibility, announcing in advance that whatever it says will be “fake news.” So why should we believe the budget office, not the Trump administration? Let me count the ways.

First, this White House already has a record of constant, blatant lying about health care that is, as far as I can tell, without precedent in modern history. Just a few days ago, for example, Vice President Mike Pence made the completely false assertion that Ohio’s expansion of Medicaid led to a cutback in aid for the disabled — a lie that the state’s government had already refuted. On Sunday, Tom Price, the secretary of Health and Human Services, claimed that the Senate bill would cover more people than current law — another blatant lie. (You can’t cut hundreds of billions from Medicaid and insurance subsidies and expect coverage to grow!)

The point is that on this issue (and others, of course), the Trump administration and its allies have negative credibility: If they say something, the default assumption should be that they’re lying.

Second, the C.B.O. is hardly alone in its negative assessments of Republican health care plans. In fact, just about every group with knowledge of the issue has reached similar conclusions. In a joint letter, the two major insurance industry trade groups blasted the Cruz provision as “simply unworkable.” The American Academy of Actuaries says basically the same thing. AARP has condemned the bill, as has the American Medical Association.

Third, contrary to White House disinformation, the C.B.O. actually did a pretty good job of predicting the effects of the Affordable Care Act, especially when you bear in mind that the act was a leap into the unknown: We had very little experience of how an A.C.A.-type system would work.

True, the C.B.O. overestimated the number of people who would buy insurance on the exchanges the act created; but that was partly because it overestimated the number of employers who would drop coverage and send their workers to those exchanges. Overall gains in coverage have been reasonably well in line with what the C.B.O. projected — especially in states that expanded Medicaid and did their best to make the law work.

Finally — and this seems to me to be the most compelling argument of all — predicting the effects of destroying the A.C.A. is much easier than predicting the consequences when it was enacted, because what the Senate bill would do, pretty much, is return us to the bad old days. Or to put it another way, what McConnell and Senator Ted Cruz are selling is a giant leap into the known, taking us back to a system whose flaws are all too familiar from recent experience.

After all, before Obamacare, most states had more or less unregulated insurance markets, similar to those the Senate bill would create. Many of these states also had skimpy, underfunded Medicaid programs, which would be the effect of the bill’s brutal Medicaid cuts.

So while careful, nonpartisan modeling, the kind the C.B.O. excels in, is important, you don’t need a detailed analysis to know what American health care would look like if this bill passes. Basically, it would look like pre-A.C.A. Texas, where 26 percent of the nonelderly population was uninsured.

And lack of insurance wouldn’t be the only problem: Many people would have “junk insurance” — insurance with deductibles so large or coverage limitations so extensive as to be effectively useless when needed.

Now, some people might be satisfied with that outcome. Hard-core libertarians, for example, don’t believe making health care available to those who need it is a legitimate role of government; letting some citizens go bankrupt and/or die if they get sick is the price of freedom as they define it.

But Republicans have never made that case. Instead, at every stage of this political fight they have claimed to be doing exactly the opposite of what they’re actually doing: covering more people, making health care cheaper, protecting Americans with pre-existing conditions. We’re not talking about run-of-the-mill spin here; we’re talking about black is white, up is down, dishonesty so raw it’s practically surreal. This isn’t just an assault on health care, it’s an assault on truth itself.

Will this vileness prevail? Your guess is as good as mine about whether Mitch McConnell will hold on to the 50 senators he needs. But the mere possibility that this much cruelty, wrapped in this much fraudulence, might pass is a horrifying indictment of his party.

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"An Open Letter to the United States Senate"
Marian Wright Edelman
Huffington Post
July 14, 2017

I learned my first lessons about injustice and health as a little Black girl growing up in segregated Bennettsville, South Carolina. I remember my parents’ and my sadness over the senseless death of little Johnny Harrington, who lived three houses down from our church and who died before he reached 10 because his hard-working grandmother didn’t know about the need for or have the money for him to get a tetanus shot after he stepped on a rusted nail.

I also remember being awakened in the middle of the night after a Black migrant family’s car collided with a White truck driver’s vehicle on the highway in front of our parsonage, and the horror I felt when my daddy, my siblings and I witnessed the White ambulance driver and attendants arrive on the scene only to leave behind the seriously injured Black migrant worker after they saw that the White truck’s passengers were not hurt.

And I remember the loss of a playmate who lived around the corner who died from a broken neck after jumping off the bridge at Crooked Creek nearby where many Black children swam and many Black families fished for food. When I got older, I learned the creek was an outlet for hospital and other sewage.

The sorrow and outrage and sense of injustice I felt as a child at senseless deaths and injuries shaped my life’s work. I cannot stand seeing any child mistreated, placed at risk or excluded from essential services because of the color of their skin or the poverty of their parents or grandparents they did not choose. God did not make two classes of children and my Biblical values and my parents’ efforts to live up to its teachings enjoined me to believe each child is sacred.

During the Civil Rights Movement it was always clear that health care was one of the basic rights for which we were fighting because it could mean life or death. As my friend and mentor Dr. Martin Luther King, Jr. famously said, “Of all the forms of inequality, injustice in health care is the most shocking and inhuman.” I would never have believed that decades later Dr. King’s words would still ring true and that after 50 years of hard-earned progress expanding access to health coverage for 95 percent of all children, it could all be ripped away in a heartless game of politics and greed that disregards human life — even the smallest human life.

In the wealthiest nation on earth, the fact that we are still unwilling to treat health care as a right available to all regardless of color, income or creed is a disgrace. That child lives are considered political fodder rather than a sacred responsibility by every adult is unjust and shameful.

You, the ever powerful United States Senate, will soon have a choice to make when Senate Majority Leader Mitch McConnell brings the deeply harmful, flawed, unpopular and misnamed Better Care Reconciliation Act (BCRA) — it should be called the Worse Care Reconciliation Act — to the Senate floor for a vote. This draconian bill will unravel decades of progress fighting for more health equity and justice for all. I hope every voter will stand up for children, the disabled, the elderly, and the most vulnerable among us and make sure those who vote against them are held accountable.

At a time when 95 percent of children in America have health coverage after years of laboriously achieved incremental progress with bipartisan leadership and the percentage of uninsured Americans is at a record low, will you vote for renewed pain and suffering or forward progress? Will you vote to end Medicaid as we know it — a lifeline for more than 37 million children and more than 40 percent of children with special health care needs — to pay for a giant tax cut for wealthy Americans and corporations who don’t need or deserve it? Will you vote to rip away health coverage from 22 million Americans and leave millions more paying a lot more for skimpier coverage? Will you vote to undermine coverage for essential services for children and other Americans including those with pre-existing conditions? Will you vote to strip important and popular protections, returning us to a day when discrimination based on age, gender, health status and ability to pay is permitted? Will you vote to deprive millions of Americans mental health and substance abuse treatment in the midst of a national opioid crisis?

You may be wooed with “fixes” being negotiated behind the scenes that tinker around the edges of the cruel, unjust Better Care Reconciliation Act, but make no mistake: it is irreparably flawed and no altering of growth rates and caps, taxes, or creating special “funds” or “risk pools” will fix it. It deserves a swift and decisive death in the Senate if we are to keep any semblance of an American sense of fairness and moral decency alive.

I have just returned from two days in the Mississippi Delta which Senators Robert Kennedy, Joseph Clark and George Murphy visited 50 years ago where they saw children with listless eyes and bloated bellies from lack of food and health care. Mississippi is one of 19 states that turned down Medicaid expansion money their people need. Health injustice still disproportionately affects people of color but those who will suffer come from every race in every state.

Would you vote to deprive your own children, grandchildren, nieces and nephews of basic life supports? I suspect not. Denying children essential health care makes no moral or economic sense. Healthy children and adults make America stronger and safer. So at this critical moment in our nation’s history, I hope you will stand up for children, the disabled, and the elderly left behind in multiple ways by the politics of greed and self-interest. Please vote NO on the misnamed Better Care Reconciliation Act — a mean-spirited, draconian, un-American step backward that would leave preventable suffering among millions in its wake.

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 "How the White House and Republicans Underestimated Obamacare Repeal"
by Nancy Cook and Burgess Everett
Politico
July 17, 2017

The longer Republican efforts to repeal Obamacare flounder, the clearer it becomes that President Donald Trump’s team and many in Congress dramatically underestimated the challenge of rolling back former President Barack Obama’s signature achievement.

The Trump transition team and other Republican leaders presumed that Congress would scrap Obamacare by President’s Day weekend in late February, according to three former Republican congressional aides and two current ones familiar with the administration’s efforts.
 
Republican leaders last fall planned a quick strike on the law in a series of meetings and phone calls, hoping to simply revive a 2015 repeal bill that Obama vetoed.

Few in the administration or Republican leadership expected the effort to stretch into the summer months, with another delay announced this weekend, eating into valuable time for lawmakers to tackle tax reform, nominations or spending bills.

As Trump himself infamously remarked, “nobody knew healthcare could be so complicated” — even though health care has reliably tripped up past administrations.

Now that the difficulty of getting 50 senators to rally around a bill has come into stark relief, Republicans are starting to acknowledge they misjudged the situation.

“It’s easier to rage against the machine when you’re not in control of the machine, No. 1. And the perception that we are in control of the machine is inaccurate,” said Sen. Tim Scott (R-S.C.).

“Needing 50 out of 52 members on the same page in the Senate? I think that is not being in control of the machine.”

The failure of the plan to quickly repeal Obamacare earlier this year forced Republican leaders to start over and attempt the daunting task of crafting a more comprehensive health care plan that would unite all sides of a squabbling conference. And the Trump administration’s lack of sufficient staff and planning for that early effort helped lay the groundwork for the legislative chaos the GOP’s agenda is mired in today.

A senior administration aide said that although the White House didn’t expect health care to take so long, the blame game will dissipate if the president signs a health care bill by August.

“If, a week from now, we have completed the repeal of Obamacare, I don’t think people looking back on it will do the woulda, coulda, shoulda game,” the aide said.

Still, rank-and-file senators now say starting with tax reform could have done more to unify the party and avoid the GOP’s ongoing quagmire.

“I would have much preferred to start off with tax. But that wasn’t my decision,” said Sen. David Perdue (R-Ga.). “Tax is the heavy lift here. It’s not going to be easier than health care. And we’ve been doing this for seven months.”

Past administrations have also been hurt by health care. Democrats said after the passage of Obamacare that they wished they had delayed the topic until more of their agenda was underway — House Democrats lost their majority in 2010 shortly after the law passed.

First lady Hillary Clinton took flak in the early 1990s for her failed health care task force, and President George W. Bush faced tremendous opposition when his administration pushed through the Medicare Part D prescription drug benefit — even though the program has cost less than original estimates.

Still, after the November 2016 election, few in Trump world or Congress saw potential problems after Republicans campaigned on killing off the Affordable Care Act for seven years.

“We are probably all guilty of not being as creative as we needed to be,” said one former congressional leadership aide. “Every administration likes to check off an accomplishment.”

During the transition, the Trump administration never established a great deal of coordination with the Hill or a concrete game plan for health care, according to congressional aides and one former transition official.

The transition had just a handful of health policy people, who were also tasked with working on the confirmation processes for Health and Human Services Secretary Tom Price and Centers for Medicare and Medicaid Services Administrator Seema Verma. The administration official said the lengthy confirmation process, which he blamed on Democrats, hurt the White House because it meant the administration did not have two key health policy experts in place.

Helping sort through the process were Marc Short, now the White House legislative affairs director; Rick Dearborn, the White House deputy chief of staff; and Stephen Miller, a senior adviser for policy. All three had congressional experience, but several Republicans said Trump’s staff lacked experience negotiating or moving major legislation.

“I just don’t have confidence that the administration had the health care expertise and policy advice that they needed there,” said G. William Hoagland, former staff director for the Senate Budget Committee and former leadership aide to Senate Majority Leader Bill Frist. “The result is what we are seeing today.”

On the Hill leading up to the inauguration, one leading idea was to resurrect the 2015 House and Senate bills that repealed much of the law. Republicans were already on the books supporting the bills, which needed only 50 votes in the Senate instead of 60.

But when GOP leaders in January pitched the idea — which involved repealing the law and figuring out a replacement later — they were met with stern resistance from lawmakers worried about constituents who had gained insurance through the 2010 law and who could lose coverage if it were suddenly revoked.

“Health care looks much easier when you’re at the talking point level,” said Larry Leavitt, a senior vice president at the nonpartisan Kaiser Family Foundation and senior health policy adviser during the Clinton administration. “It always gets more difficult as you start filling in the details.”

This was the first hint of real trouble for the Republican health care efforts. Passing a bill they knew would be vetoed under Obama was easy; passing one that would thrust their constituents into uncertainty was riskier.

“When you’re six years into a program, to change it when people are relying on it, there’s a fear that it may affect their own policies or their own families,” said Sen. Jeff Flake (R-Ariz.). “This is tough; this is complex. We knew it would be, but it’s really tough.”

In late January, lawmakers at a closed-door session at a Republican retreat in Philadelphia raised a myriad of concerns about tackling Obamacare, from the contours of the replacement plan to ways to keep premiums affordable. One former Republican Senate aide later called that meeting with Andrew Bremberg, the head of the White House’s Domestic Policy Council, prescient, because lawmakers privately raised many of the concerns that have since dogged the bill.

At the same policy retreat, House Speaker Paul Ryan laid out a three-pronged approach to scrapping Obamacare. He wanted to repeal as much of the legislation as possible, eliminate more through deregulation, and then work with Democrats on a replacement, said one former Republican aide.

Many Republican lawmakers doubted Democrats would work with them on redoing the health care law.

The president and one of his former campaign rivals also unexpectedly helped undermine the GOP’s repeal plans. Sen. Rand Paul (R-Ky.) said on television the GOP needed a replacement plan if it was going to repeal the law. Then Trump endorsed that requirement. Their comments caused GOP leaders to start from scratch.

Now that the Senate’s attempt to revamp the health care law has run into roadblocks — with moderates insisting on protecting coverage for their constituents, while conservatives focus on undoing as much of Obamacare as possible — both Paul and Trump have suggested going back to a repeal-only bill.

Many Republicans say that’s unworkable now.

“We’re not just trying to get rid of the law, we’re trying to replace it with something better. Getting rid of it is pretty straight-forward,” said Sen. Marco Rubio (R-Fla.). “Replacing it with something better is a significant undertaking, but it needs to be done.”

Now, Senate Majority Leader Mitch McConnell maintains that the Senate will vote soon, though he was forced to delay again while Sen. John McCain (R-Ariz.) recuperates from surgery. With two Republicans saying they will definitely vote no, the bill could not pass without McCain present. Other senators are still undecided.

“They’re trying to turn around a massive piece of public policy that has been the law of the land for seven years,” said Lanhee Chen, policy director for the 2012 Romney-Ryan presidential campaign. “One cannot overstate the magnitude of what is being attempted. This is a totally unique experiment in some ways.”

In the meantime, neither the White House nor Congress wants to claim responsibility if it doesn’t work out. While lawmakers grumble that Trump should have started with an easier policy goal, White House aides say they assumed congressional Republicans had it under control.
 
Republicans had campaigned on undoing Obamacare since 2010, the senior administration official said: “That was not contingent on President Trump.”