The rubber has hit the road. Populist Trump, has to deliver on his promise to make health care more affordable and available to everyone while repealing the “disastrous Obamacare”. That has to be effected while, simultaneously, ensuring the passage of a health care act acceptable to the Republican legislature. The disunited GOP, which up till now has been able to paper over its vast divisions, has to cobble together legislation that the differing philosophical wings agree to in order to “repeal and replace”.
As Jay H. Ell has blogged repeatedly, notwithstanding the across the board Republican victories, the Party is far less united than the Democratic Party. The latter are expected to vote en bloc against any Republican proposal. As matters stand there are Republican legislators that are totally against any subsidized health care while there are those that want to hang onto at least the current number insured or even increase the numbers. Unless a miracle happens the Ryan’s bill, the American Health Care Act, (AHCA), which currently pleases neither Republican faction, is D. O. A - dead on arrival. Even if it passes the House the Senate objectors seem immutable.
America, like health care, is “very complicated”. There are major constituencies and interest groups that impact a decision of this nature. Obama with all his majorities and a clear mandate ended up with a bastardized plan after eight months of negotiation and compromise. Trump promised an improvement on the status quo and whether the Republican legislators like it or not, implicit in their repeal and replace mantra there is an expectation from the electorate for more health care not less.
So the players are; the electorate, the Governors of States, the Legislature, the Institutions and Pressure Groups and finally the POTUS himself. But before examining their input the plan itself needs explanation.
THE PLAN AS IT STANDS.
There are two components repeal and replace Obamacare or Affordable Health Act, (ACA). The repeal is easy and the GOP have done the latter sixty times in the Obama era when they never had the responsibility to replace it. If the Conservatives in the GOP had their way that is all that they would do. However, that would negate election promises which in one way or another promised to replace it with something “better”.
Well, instead, the new plan gets rid of the component that extends Medicaid, the insurance for the poor. It eliminates the monetary subsidies and replaces them with tax credits, for those with lower incomes that don’t qualify for Medicaid. These credits are a complicated process to collect and don’t provide the cash there and then to pay. The analysis is that the whole maneuver will ensure drop outs from insurance cover. Then these tax concessions are based on age rather than income, disadvantaging those with lower incomes. However, the AHCA allows for seniors to be charged up to five times as much as compared to the youth by insurers. The mandate for everyone to enroll is removed so the healthy young will opt out thereby placing a greater onus on the seniors to cover the whole burden, therefore risking skyrocketing premiums. The tax on the rich associated with the Affordable Care Act, (ACA), has been removed so the rich benefit decidedly by the new dispensation.
The Ryan effort lays the ground work to axe Planned Parenthood the organization that provides reproductive health services and other primary care services in six hundred and fifty clinics across the country. It serves close on three million patients and in 2014 performed nearly ten million individual services. The money that it receives from the Government is in return for Medicaid interactions and is not a straight grant. The reason for the anger, which will throw an already dysfunctional health system into greater disarray, is that Planned Parenthood provides abortion services in 3% of it’s clinical activities.
The good news is that the Ryan plan still mandates insurance companies to not exclude patients on the basis of pre existing conditions and still allows children up to the age of twenty six to remain on their parents plans. Even better news for the Republicans is that the AHCA is programmed to come into effect in 2020 so that it is unlikely to impact the mid term and the 2020 Presidential election.
THE ELECTORATE AND THE GOVERNORS OF THE STATES:
The recent congressional recess saw pandemonium at the Republican town hall meetings at the threat of removing “Obamacare”. The message was loud and clear - Don’t touch what we have already. The number that are covered to date as a result of Obama’s Affordable Care Act, (ACA), is twenty - million. The enrollment for 2017 shot up dramatically to six and a half million. The recruitment number is far more than last year which fact has to be indicative that many believe this is their last chance for coverage.
The Obama ACA increased coverage by two methods - by increasing the pool of Americans eligible for Medicaid which is the entitlement program for those in the lowest income bracket and by creating a program whereby those without insurance could gain acceptance. Some of those lower income groups who didn’t qualify for Medicaid received subsidies. This was especially attractive for those with preexisting conditions, who previously were excluded from insurance. With regard to the Medicaid expansion program, thirty - two of the fifty states adapted it. (Some of the eighteen that didn’t are having serious second thoughts on the matter). Several of the States that signed on are Republican controlled. Most significantly the key rust belt States, that swung the Electoral College to Trump, participate. The majority of angry whites who had lost manufacturing and mining jobs are recipients of Obamacare. (Remember they were voting for a replacement that was bigger and better).
It is obvious where the Dem Governors stand but they have Republican bed fellows. The ACA dished out nearly a hundred billion to the participating States and the Republican Governors still want their share. In addition they don’t want the flack from those that will either lose coverage or pay more for it. John Kasich of Ohio, a crucial State in the populist’s surprise victory, has lead the charge not to alter the status quo. Kasich has advocated that the GOP cooperate with the Democrats to improve Obamacare. Now the Congressional legislators in the affected States also need to give the issue one long hard look and some already have. Senators from Ohio, West Virginia, Alaska, Colorado and Maine have already have signaled that they are not on board. Added to the State opposition a hundred and thirty mayors have signed a letter to register their concerns on the repeal of the ACA.
CONSTITUENCIES WITHIN THE GOP LEGISLATURE
The Congress is the first problem for Ryan’s legislation. The AHCA is ostensibly a compromise between the two viewpoints - repeal and don’t replace and repeal and replace with “something”. Remember there are two mechanisms whereby Americans have obtained insurance under the ACA - Medicaid expansion and the newly created pools for individuals. The proposed legislation faces the biggest challenge in the Senate where there are fixed opinions on both sides of the Republican divide. There are at least five GOP Senators that won’t truck a plan that excludes the Medicaid Extension Plan and a similar number who want no replacement entitlement component whatsoever. There are reports that potentially there are up to twenty Republican Senators that for different reasons might vote against the Ryan plan or what Senator Schumer calls “Trumpcare”. Only three Republicans need to switch to defeat the Bill. Even if the bill survives the House, as matters stand at the moment it would take a major shift in positions for it to pass the Senate.
The House of Representatives most vocal opponents are those that were elected under the Tea Party banner. They now refer to themselves as the Freedom Caucus. These are not exactly middle of the road players open to compromise. Their position is that there should be no entitlement component, period. There are forty of them and they generally move as a pack. There are several other Congressmen who object to the Bill as it stands, a few of them objecting to the loss of coverage. It is not for nothing that Ryan labels his effort as “conservative” as that is the constituency he has to convince to go with him to hustle this through the House. Twenty House Republicans voting against are enough to kibosh the whole venture.
According to Fox News the non partisan Congressional Budget Office analysis has declared the AHCA more expensive and will cover fewer. Fox stated that their sources believed that this will make Ryan’s and Trump’s task that much harder. The Secretary of Health Tom Price has attempted to reassure by claiming the draft bill can be amended -“It is a work in progress”. The Brooking’s Institute’s projections are that with the AHCA fifteen of the twenty - million who gained insurance on the ACA will lose it within ten years.
THE INSTITUTIONS AND PRESSURE GROUPS.
The Republican conservative think tanks have been unequivocal in condemning the plan as a sell out. Terms like Obamacare Light have been bandied about to characterize the offering. The influential Heritage Foundation labelled the AHCA, Obamacare 2, bad politics and bad policy. The Club for Growth have sarcastically dubbed the effort “Ryancare”. Joe Antos of the American Institute, the Cato Institute as well as The Tea Party Patriots slammed the operation claiming that the Republicans are reneging on their commitment for full repeal of Obamacare. The influential mega donors, The Koch Brothers, who have literally poured tens of billions of dollars into electing candidates so that this day would arrive, are screaming fowl.
The real pressure groups who can line up citizen votes are basically on the “adequate replacement” side of the divide. The American Association of Retired Persons who have a membership of nearly forty million have unequivocally panned the new health care act. They maintain that senior citizens come out very badly especially as the insurance companies have been given the green light to charge fees up to five times more than the young subscribers. To add insult to injury the elderly tax credits are relatively far less than their younger counterparts.The American Hospital Association say that with the reduction of Medicaid enrollees they will be providing more free care. They claim that rural hospitals are at risk and may have to close as most are barely covering costs at the moment. The American Medical Association, (doctors), and the American Nursing Association have expressed alarm and have declined to support the prospective legislation on the basis that it would result in the decline in insurance coverage and the harm it would cause to the most vulnerable populations. The celebrated Kaiser Foundation medical think tank have added its findings to the mass of research that indicates a negative impact on health care. The American Medical Insurance Association objections to the AHCA leaves the Ryan/Trump endeavor with no organized medical administrative support.
Then the Academic bodies of medicine of virtually every major discipline have weighed in. These include the Association of American Colleges, Family Medicine, Internal Medicine, Pediatrics and Osteopathy. Medscape a site that provides information to the profession reports that the American Public Health Association put forward that the bill would jeopardize the health and lives of millions of America people. They point to the eradication of a key component of the ACA that provides twelve percent of the funding for the Center of Disease Control and Prevention, is dropped.
So from both ends of the political spectrum there are the flood of lobbyists and activists that are against the bill and none on the record as supporting it.
THE POTUS
Trump after initially being blasé about the whole process has committed himself holus bolus to the Ryan endeavor. In supporting the AHCA he has broken a key campaign pledge to increase medical coverage to every American, making it more affordable and of a higher standard. (This type of betrayal doesn’t worry The Donald because when the time comes he will go into the bullshit mode and lie his way around it). His stated objective is to persuade the conservative non believers to go along with the AHCA in what will be a crucial test for his Presidency. If he can’t pull the Party together he will have failed as its leader. While the velcro Trump has proved everyone wrong time and again, he seems to have his work cut out this time. However he is already tweeting that if the bill doesn’t pass it will be the Democrats fault!
The fact that the Republican Congressional leaders of the “repeal only” group have already come out in opposition rather than wait to negotiate and speak with Trump does not augur well for his ability to persuade them to go along for the greater good of the Party. Maybe he wasn’t around for the Tea Party takeover of the GOP. They got in before him and they have enough votes to dictate the direction of the Republican Party. Ask former House Speaker Boehner who lived through it all till his position became untenable. He has predicted that repeal and replacement is not going to happen.
AT THE END OF THE DAY
For Trump the defeat would be a major set back which will put him on a path of tweeting and accusing. He owns it whether he likes it or not. It is not for nothing that the Democrats insist on calling the AHCA, “Trumpcare”. Who knows what pressure he will apply to “Seal the Deal”.
If the bill fails the deficiencies of Obamacare must be immediately addressed. In a sane world it would also present an opportunity to revamp the most costly inefficient healthcare service in the world. It chews up one out of every six dollars, sixteen percent of GDP, far more than in comparative countries. The administrative costs are an unholy thirty percent of that total - about a trillion dollars. Hospital and Health System CEO’S earn millions. Health care costs are the commonest cause of individual bankruptcy. Ironically more and more of those who can afford it leave the country for elective medical procedures. There is an incredible imbalance in the distribution of medical specialties making the country dependent on internationally trained doctors to fill in the gap for Primary Care and rural services. (This would be exacerbated in Planned Parenthood got the chop). Trump’s projected Muslim ban left a big gap in some Residency Programs even though it involved only a few Middle East countries. Malpractice litigation increases costs dramatically as Doctors practice defensive medicine ordering test after test. Just to highlight some of the issues.
Ironically, Hillary Clinton’s 1990’s plan came the closest to addressing the American health care problem that involves educational institutions as well.
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