GOP Senators: Where's Your Heart?

Senate Republicans are pushing hard for a vote this week on their plan to repeal and replace Obamacare, aka the ACA.   But the Senate plan takes coverage away from 22 million Americans, according to a report from the Congressional Budget Office released on Monday.  The CBO also projects the plan will reduce the deficit by $321 billion over the next decade.  And the bill's authors utilized some trickery to get their bill scored slightly better than its House counterpart proposal, which President Donald Trump called "mean."   

The Senate GOP proposal will phase out Medicaid's expansion, it will cap Medicaid spending to the states, it will repeal Obamacare taxes used to fund the program, and it will restructure subsidies to insurance customers.   The federal government currently picks up between 50 and 100 percent of the states' healthcare costs.  The Republicans want to reduce these costs through block grants that are capped to slow growth.  This will leave it to the states to cover any difference and administer healthcare.  But the effect will be to reduce federal Medicaid spending over time, leaving millions of those who need support most without health insurance.   

In January President Donald Trump told The Washington Post, "We are going to have insurance for everybody.  There was a philosophy in some circles that if you can't pay for it, you don't get it.  That's not going to happen with us."   The House GOP earlier had passed their version of health care, which President Trump feted at a White House ceremony with Congressional Republicans.  But later he turned on them by describing the bill as "mean."  Now he is pushing for passage of the Senate Republican bill, which is not dissimilar to the House version.  

Health care represents one sixth of the U.S. gross domestic product, or more than $2.6 trillion.   Medicaid spending has reached $575 billion annually.  The Health Insurance Association of America defines Medicaid as a "government insurance program for persons of all ages whose income and resources are insufficient to pay for health care."  Republicans have long strived to cut Medicaid costs in an effort to reduce the U.S. deficit.   They believe that block granting it to the states will make it more efficient.

The federal government's options for reducing Medicaid costs are limited.  It can reduce the number of people covered, it can reduce the benefit coverage, it can pay less for benefits, it can get doctors and hospitals to accept less in reimbursement, or it can ask beneficiaries to pay more.  Both the House and Senate bills would have a devastating impact millions of Americans by throwing the problem to the states and cutting the growth of Medicaid subsidies over time through a cap on spending.    While the CBO shows that healthcare price increases will in a couple years be less under the Senate version than Obamacare, those covered will get less for their money.  

For more than seven years Republicans have railed against Obamacare.  President Trump campaigned heavily against Obamacare, pledging at a Florida rally in October to repeal and replace it.  "That begins with immediately repealing and replacing the disaster known as Obamacare," he promised.  "You're going to have such great health care, at a tiny fraction of the cost--and it's going to be so easy."   Four months later a frustrated President Trump told reporters,  "It's an unbelievably complex subject.  Nobody knew health care could be so complicated."   

Senate Republican leadership turned this complicated task over to thirteen of its members, all men, who then crafted its health care bill behind closed doors.  The measure was released to the public last Thursday, leaving little time for public scrutiny.  The Affordable Care Act, by contrast, was debated over months of hearings and Republicans added more than one hundred amendments to the legislation.   Clearly Senate Leader Mitch McConnell knew his caucus's bill would be unpopular.  But now President Trump is championing the Senate bill, even though it will adversely impact millions of his own supporters while giving tax breaks to the rich, like the Trump family.  All Trump, a self-proclaimed dealmaker, cares about is making a deal.

Ultimately, someone has to pay if health care is to cover those who can least afford it.  The American Medical Association sent a letter to Leader McConnell warning that the Senate's Obamacare repeal plan could hurt America's "most vulnerable citizens."  The key to covering more Americans while lowering health insurance costs is risk sharing, where the healthy contribute to pay the costs.  But Congressional Republicans are more focused on fulfilling their campaign promise to repeal Obamacare, even at the risk of losing Congressional seats in the 2018 Midterm elections, especially in those states that have already accepted Medicaid coverage.  

Yet President Trump is exhorting Republicans on Twitter--driving them to close the deal and perhaps off the cliff in 2018.  "Republican Senators are working very hard to get there, with no help from the Democrats.  Not easy!  Perhaps just let OCare crash & burn!" he tweeted Monday.   Of course it would be easier to fix Obamacare, and former House Speaker John Boehner warned Republicans that once you give people and entitlement you can't take it away.

So Republicans have replaced a "mean" proposal with a less mean proposal.  Now passage rests in the hands of a handful of uncommitted Senate Republicans.   Were Hippocrates, the father of medicine in Western Culture, alive today he would give each of them this advice:  "Do no harm."

But this is politics, and nobody knew it could be so complicated.    

Obamacare: Don't Stop Believing

President Barack Obama has been rightly criticized for the launch of the    Affordable Care Act. But the fact is that the president did do something historic and morally right by giving almost all Americans access to health insurance.  Yes, the ACA website has been a disaster. Yes, some people are getting cancellation notices from their insurance company despite the president's campaign pledge that, "If you like your current plan you can keep it." However, the website will be fixed at some point. And the cancellations are largely due to the fact that those policies did not meet minimum standards. In fact, many people were being ripped off and didn't know it. But these problems have given Republicans another reason to attack healthcare. They have tried everything to repeal, defund and denounce the president's signature program. Republicans have lied about the program, "death panels" anyone? They claim it's a job killer (wrong) and it will add to the deficit (wrong). The Republican controlled House of Representatives has voted 46 times along party lines to defund Obamacare to no avail. The Supreme Court has upheld the law, and President Obama ran, in part, on the health care law and got reelected in 2012. So computer problems, while embarrassing, are just another hurdle to implementation. But change is not easy. When Medicare Part D was launched in 2005, its website was not available for months. Few patients who had signed up received prescription insurance cards, which caused huge problems for pharmacists filling prescriptions. No one is complaining about President George Bush's program now, even though it has added billions of dollars to the deficit. And the Massachusetts health care law, Romneycare, which the ACA is modeled after, was enacted in 2006, had technical problems, has been amended twice, but is successful today.  While many Americans may be frustrated with the problems encountered by Obamacare, at least the president did something about the growing healthcare nightmare. Republicans don't have a real alternative; they just talk. Take Senator Ted Cruz, who told NBC's Jay Leno that he's a "big believer in health care reform." Sure, and the Calgary Stampeder has got a plan! "I think we ought to reform health care so it's personal, it's portable, it's affordable. We ought to empower patients rather than government bureaucrats getting between you and your doctor," he told Leno.  Perhaps in a more truthful moment, just last August Cruz criticized the president and Obamacare to a Texas Tea Party group, "His strategy is to get as many Americans as possible hooked on the subsidies, addicted to the sugar." He warned, "If we get to January 1, this thing is here forever." Of course, Texas has the highest number of uninsured residents in the nation. That is why the president was in Dallas last week promising Texans access to affordable health care, vowing, "to get this done." But the president was also busy last week apologizing to those Americans who have seen their current plans cancelled. "I am sorry that they, you know, are finding themselves in this situation, based on assurances they received from me," he told NBC News. "We've got to work hard to make sure that they know we hear them and that we're going to do everything we can to deal with folks who find themselves in a tough position as a consequence of this." The apology seemed genuine, and there is no reason to believe the president misled the country in order to get Obamacare passed, even in the face of all the Republican lies about the ACA.  The healthcare train has left the station, albeit with some struggles. And there will be other hurdles ahead for the law. But, as more Americans see the options that are available to them, they will understand the true significance of Obamacare. And then they will be "addicted to the sugar!"

Fix the Glitches

The government shutdown was a misguided and senseless tactic that cost American taxpayers at least $24 billion and damaged the Republican brand.  But the error-plagued rollout of the Affordable Care Act, or Obamacare, has given the GOP a way to change the conversation.

Senator Ted Cruz's reckless strategy to defund Obamacare was never going to succeed.  But he knew that.  However, the ambitious Cruz saw it as tremendous opportunity to galvanize Tea Party members behind his leadership.   And, while moderate Republicans call his maneuvers a "fool's errand," there is no question Cruz has now won the loyal support of many on the right.

Yet many Republicans are shaking their heads in frustration because the Cruz shutdown has taken attention away from Obamacare's problems.  "The fiasco of rollout has been obscured because of this internecine strife that's been going on in the Republican Party," Senator John McCain (R-AZ) said Sunday on CNN.  "Keep up the fight against Obamacare, but don't shut down the government and have so much collateral damage to innocent Americans."

However, out of the GOP wreckage will quickly emerge an all out attack against the problem-plagued launch of Obamacare.  On CBS's Face the Nation Sunday, Senate Minority Leader Mitch McConnell called Obamacare,  "The worst piece of legislation passed in the last half century...we need to get rid of it." He claimed that even if one can get on the site, they will find fewer choices and higher costs.

Democrats recognize that the faulty rollout is an issue ripe for exploitation.   Last week on MSNBC, Former White House Press Secretary Robert Gibbs called it, "Excruciatingly embarrassing for the White House and for the Department of Health and Human Services." On ABC's This Week, former House Speaker Nancy Pelosi called the problems "unacceptable."  She added, "This has to be fixed, but what doesn't have to be fixed is the fact the tens of millions of more people will have access to affordable healthcare, quality healthcare.  That no longer having a preexisting medical condition will bar you from getting affordable care." 

The White House and HHS have had years to prepare for the launch of Obamacare.  All along they have said that Republicans oppose it because Americans will fall in love with it once it is available.  But now the architects of President Obama's signature legislative achievement are vulnerable to attack and relentless scrutiny from Congressional Committees.  Republicans would like nothing more than to turn Obamacare against Democrats in the 2014-midterm elections.

Already Republican Chairmen Fred Upton, of the House Energy and Commerce Committee has announced he will investigate.  "It is well past time for the administration to be straight and transparent with the American people," he said in a statement last week.  For instance, how many millions of dollars were spent to design the error plagued software?  Whose fault is it that the program has failed?

President Obama is expected to address the health care glitches on Monday.  While making health care accessible for all remains a worthy goal, and millions of people have already tried to learn more about the offerings, the problems must be quickly remedied.  If the president fails to make that happen, Obamacare may damage his ability to achieve any further legislative successes.

Mr. Obama has already stated his intention to pivot onto the difficult and complex issue of immigration reform.  He has also indicated he is interested in achieving a budget deal with Republicans that will include infrastructure, tax and entitlement reform.   But the problems with Obamacare will weaken his position.

Republicans are mindful of the words once spoken by the president's former chief of staff, Rahm Emanuel, "You never want a serious crisis to go to waste."