Trump Vows To Make Healthcare An Issue After McConnell Nixes Repeal Effort

President Trump surprised many people with his pivot to health care last week. Now it seems that Senate Republicans were just as surprised as the rest of the country. Now Majority Leader Mitch McConnell is saying definitively that the GOP is not ready to move ahead with another attempt to repeal and replace Obamacare.

Speaking with reporters on Tuesday, McConnell said, “We had a good conversation yesterday afternoon and I pointed out to him [Trump] the Senate Republicans’ view on dealing with comprehensive health care reform with a Democratic House of Representatives.”

“I was fine with Sen. Alexander and Sen. Grassley working on prescription drug pricing and other issues that are not a comprehensive effort to revisit the issue that we had the opportunity to address in the last Congress and were unable to do so,” McConnell said. “I made clear to him that we were not going to be doing that in the Senate.”

Health care reemerged as a campaign issue last week when the Trump Administration advocated that judges in a lawsuit should strike down the entire law. On April 1, President Trump announced that Republicans were “developing a really great HealthCare Plan with far lower premiums (cost) & deductibles than ObamaCare.”

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After the conversation with McConnell, the president tweeted this morning that he never intended to hold a healthcare vote before the election. Mr. Trump reiterated his belief that healthcare, an issue on which the Democrats usually hold an advantage, would be a “great issue” for Republicans.

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The Republican reversal leads to several questions. The most obvious is whether there was any communication between Republican leaders in the healthcare pivot or whether Mr. Trump merely tweeted an off-the-cuff remark that shifted the entire strategic planning of the Republican 2020 effort. It seems likely that the GOP reacted to an unplanned announcement by Mr. Trump.

A second question is how the GOP can co-opt the issue of health care from the Democrats. As I noted last week, the previous Republican effort at repeal succeeded in shifting public opinion from favoring repeal of the Affordable Care Act to an all-time high level of approval of the law. Unless Republicans can coordinate a strong message that calms voter fears about losing coverage, the health care issue is more likely to be beneficial to Democrats.

Third, there is apparently no change in the Trump Administration’s position that courts should strike down the ACA. Are Republicans planning for the possibility that this ruling could come in the runup to the election? Do they have a plan to take advantage of the opportunity to pass a market-based healthcare reform?

Regardless of the questions and current lack of organization and planning, President Trump apparently intends to continue hammering away on healthcare. At the National Republican Congressional Committee’s annual spring dinner last night, Trump said, “We blew it the last time, man I was fed a bill of goods,” but added “we can’t run away” from healthcare or “we’ll lose.”

The back-and-forth on healthcare is reminiscent of the Keystone Kops with positions being reversed at a head-spinning rate. With Democrats in control of the House, there was never any chance that Obamacare could be repealed before the election, but President Trump has handed Nancy Pelosi an issue with which to hammer Republican candidates next year.

Originally published on The Resurgent

Trump DOJ: Courts Should Strike Down Obamacare Entirely

It had seemed that everyone had forgotten about Obamacare, but this week the Trump Administration, apparently deciding that the president’s vindication in the Mueller report had gotten too much press, said that it believes that courts should strike down the entire Affordable Care Act. The sudden and short announcement came Monday as the Department of Justice notified the Fifth Circuit Court of Appeals that it supports a December ruling striking down the law.

“The Department of Justice has determined that the district court's judgment should be affirmed,” three Justice Department lawyers wrote. “The United States is not urging that any portion of the district court's judgment be reversed.”

The appeals court is currently reviewing a December ruling by U.S. District Court Judge Reed O’Connor, a George W. Bush appointee, who said that Congress’s decision to scrap the penalty for failing to purchase health insurance meant that the entire law should be struck down. The decision was immediately appealed by a group of states defending the law led by California Attorney General Xavier Becerra.

“The Individual Mandate ‘is so interwoven with [the ACA’s] regulations that they cannot be separated. None of them can stand,” O’Connor wrote.

The Trump Administration had previously argued that community rating and guaranteed issue of policies should be struck down, but that the rest of the law should be upheld. The two provisions benefit people with pre-existing conditions who want to buy health insurance after they become ill.

The announcement by the Justice Department comes almost two years after Republicans were unable to repeal or reform the Affordable Care Act in President Trump’s first year in office. While the health insurance law has largely withstood attempts to repeal or change it, a provision was inserted into the Tax Cuts and Jobs Act that repealed the individual mandate. The tax reform law passed in December 2017.

As the lawsuit against Obamacare winds its way through the judicial system, Congress is at a stalemate on the law. Republicans promised to repeal the law but don’t have the votes to do so. Even a “skinny repeal” using a budget reconciliation requiring only 51 votes failed after several Republican senators expressed concern about coverage for pre-existing conditions. For their part, many Democrats acknowledge that Obamacare needs to be reformed. The party is united in opposition to repeal but can’t agree on how to fix the law.

In the meantime, the one effect that the Republican repeal effort has had is to make Obamacare more popular. Voters opposed the law until April 2017 when doubts about Republican bills suddenly caused a surge in popularity for the Affordable Care Act. Support for Obamacare hit an all-time high just before the 2018 elections when Reuters found that 60 percent opposed repeal.

The lower court ruling and the Trump Administration’s support for it are the equivalent of throwing a live grenade into the 2020 elections. Where health care was not a large issue, it is suddenly reemerging as a hot topic for voters and Republicans incumbents are likely to start jumping for cover.

Even though Obamacare has never been popular within the GOP, many Republican voters are among those who do support various aspects of the law. Coverage for preventive care with no out-of-pocket expenses, protections for pre-existing conditions, and coverage for dependents up to age 26 have broad support across party lines.

Regardless of its popularity, the Affordable Care Act has not achieved its purpose. The growth rate in health care spending has declined only marginally and health insurance premiums have continued to steadily increase. The law never eliminated the problem of uninsured Americans although it reduced the uninsured rate to 8.8 percent by 2018. Today, the share of Americans without adequate health insurance is essentially unchanged since 2010.

Nine years after its passage, the Affordable Care Act remains a drag on the economy and the high cost of health care is still a problem that needs to be fixed. With the parties unable to reach an agreement on how to reform the health law, the possibility that the Supreme Court could strike down Obamacare in its entirety introduces a new uncertainty into next year’s elections. The timing of the case could once again force Republican incumbents to choose between pleasing the Republican base or the majority of voters.

Originally published on The Resurgent

McSally "Getting Ass Kicked' In Arizona

Once thought to be a favorite, Republican Martha McSally is slipping in the polls in Arizona. The conservative vying for Jeff Flake’s Senate seat blames her decline on her 2017 vote to repeal Obamacare.

In an interview on Sean Hannity’s radio show quoted by Raw Story, McSally said, “Well, Sean, I did vote to repeal and replace Obamacare on that House bill — I’m getting my ass kicked for it right now because it’s being misconstrued by the Democrats. They’re trying to, you know, invoke fear in people who have family members or loved ones with pre-existing conditions.”

McSally told the Arizona Republic that Democrats were assassinating her character because of her vote even though many people with pre-existing conditions are not covered by Obamacare plans due to their cost.

“Now what we have is people right now, under Obamacare, with pre-existing conditions who have no health insurance,” she said, adding that people didn’t want the “crappy insurance” created by the Affordable Care Act.

Since the Affordable Care Act was passed in 2010, Republicans have made repealing the health insurance law a priority. Public opinion was against the law for years but shifted when Republicans launched several abortive attempts to repeal and replace it last year. Current polling shows that Americans now approve of the law by an average of nine points. Democrat claims that Republicans would eliminate coverage for pre-existing conditions was a major reason for the shift.

While polling remains close in the race, momentum seems to have moved towards Democrat Kirsten Sinema in recent weeks even though Arizona typically trends Republican. Sinema was also faced with an embarrassing video a few weeks ago in which she ridiculed Arizona voters.

The Real Clear Politics average gives Sinema a lead of less than one point, but recent polls favor the Democrat by larger margins. The last poll, released yesterday, showed Sinema with a six-point lead that is outside the margin of error. The Cook Political Report and Larry Sabato still rate the race as a tossup, but FiveThirtyEight has moved the Arizona to the “lean Democrat” category, pegging McSally’s chances of winning at 38 percent.

McSally, a former Air Force fighter pilot who flew the A-10 Thunderbolt in combat in Afghanistan, has served as a Republican congressman from Arizona since 2015. She has been a strong ally of Donald Trump, voting with the president more than 97 percent of the time.

Arizona seems to be the best chance for Democrats to pick up Republican Senate seat, but, if Sinema pulls off the win, it may only be to preserve the current balance of power in the Senate. Flipping Flake’s seat would only offset the projected Republican victory over Democratic incumbent Heidi Heitkamp in North Dakota. With Democrats on the defense in most other close Senate races, it seems increasingly likely that the blue wave won’t reach the Senate, even if Arizona goes blue. 

Originally published on The Resurgent

GOP Lawsuit Attempts To Kill Obamacare (Season 8 Episode 1)

Congressional Republicans no longer seem to be talking about repeal or replacement or reform of Obamacare, but that doesn’t mean that the effort to rid the country of the onerous health insurance law is dead. The latest attempt on the life of Obamacare comes from Texas Attorney General Ken Paxton and early indications are that it may have a better chance at success than previously thought.

The lawsuit is based on the facts that Justice John Roberts’ majority decision preserved the Obamacare mandate as a tax and that Republicans later eliminated the tax penalty for not purchasing health insurance, essentially eliminating the mandate. The Republican plaintiffs argue that the Affordable Care Act is now unconstitutional because the law depended on the mandate to make the system work and the mandate has now been removed.

“There is no real true mandate because the tax is eliminated,” Darren McCarty, special counsel for the Texas Attorney General’s office, argued in federal district court. “The ACA is unconstitutional on its face.”

The Texas lawsuit has been joined by 20 states and the Trump Administration Department of Justice. While the state attorneys general are asking for the court to strike down the entire law, the DOJ is only seeking to invalidate certain portions of the law such as those that deal with coverage for people with pre-existing conditions and limits on how much insurers can charge people based on gender and age.

Defense of the law has been picked up by Democrats who argued that striking down the law would harm the millions of Americans with pre-existing conditions.

“The harm of striking down the ACA…would be devastating,” said Nimrod Elias, a California deputy attorney general defending the law.

The case hinges on whether Congress eliminated the mandate by removing the penalty. While the mandate is still technically part of the law, it will be unenforceable when the penalty expires.

Telltale signals from U.S. District Judge Reed O’Connor give opponents of the law hope for a friendly ruling. Observers said that O’Connor’s line of questioning often echoed the views of the Obamacare critics. The judge also asked questions about severability, whether other parts of the ACA could remain in force without the individual mandate.

O’Connor, who was appointed by George W. Bush, has ruled against the ACA in the past, issuing a temporary injunction against a regulation prohibiting price discrimination based on age and gender in 2016. Judge O’Connor said that he will deliver a ruling as quickly as possible, meaning that a decision before the midterm elections is likely.

Whether the decision strikes down all or part of the ACA or lets it stand, it could have an effect on the midterms. Democrats are using the threat to the law, which has become more popular since Donald Trump took office, to build support for midterm candidates. For their part, Republicans would use a decision against the law to show their base that they are making progress against government encroachment.

Conservatives shouldn’t get their hopes up. Lawsuits against Obamacare that looked more promising have all gone down to defeat and if O’Connor rules against the law, Democrats are certain to appeal. The case could eventually have the Supreme Court rule once again on the constitutionality of Obamacare.

In the meantime, a ruling against the law could not come at a worse time for Republicans. With GOP candidates already battered by association with an unpopular president, a ruling that allows Democrats to paint Republicans as hostile to people with pre-existing conditions would not help the party’s chances of holding Congress.

Originally published on The Resurgent

GOP Gears Up For Another Go At Obamacare

Long thought to be dead, the effort to repeal the Affordable Care Act may have just gotten a new breath of life. A group of Republicans has introduced a new bill to repeal the law, commonly referred to as Obamacare, and replace it with a new structure that returns regulatory power to the states.

The Wall Street Journal reports that the bill is the work of a coalition of groups such as the Heritage Foundation and the American Enterprise Institute. The plan contains some elements of last year’s ill-fated reform plan authored by Sens. Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.). Sen. Graham is reportedly working separately on another health reform bill.

The plan reportedly centers on the use of block grants to states rather than itemized funding. Half of the grants would support the purchase of private health insurance for individuals and the other half would help cover low-income individuals. The bill would ban states from using the grant money to fund abortion. The new law would repeal the Medicaid expansion and allow Medicaid recipients to buy private health insurance.

The bill is expected to garner support from conservative Republicans such as Sen. Ron Johnson (R-Wisc.), who has expressed interest in another attempt at reform, but will face hurdles from moderates. Republican congressmen engaging in tough reelection battles may resist tackling the controversial topic immediately prior to the midterm elections.

While a repeal bill would be welcomed by the Republican base, last year’s attempt at repeal was not popular with voters. Although Obamacare was historically unpopular, the law received a boost from the Republican reform effort. Current polling from the Kaiser Foundation shows that voters are split on the ACA, but the law has a net positive approval rating.

Repeal of Obamacare has long been a Republican goal and was a main campaign promise of President Trump, but there are long odds against the effort. The Republicans’ slim 51-seat majority means that a repeal attempt would face a certain Democrat filibuster. A bill that would be supported by Democrats and Republican moderates would likely not be supported by GOP conservatives.

The midterm elections may seal the fate of the repeal effort. If Republicans lose their majority in either the House or the Senate, any serious effort to repeal the ACA would be doomed. At that point, the best that Republicans could hope for would be a bipartisan effort to fix the worst problems of the law.

Originally published on The Resurgent

Trump Administration Won't Defend Obamacare In Court

The Trump Administration has announced that it will no longer defend the Affordable Care Act in court, claiming the Obamacare law is unconstitutional. The move mirrors a decision by the Obama Administration to end government legal defense of the Defense of Marriage Act in 2011.

The Supreme Court upheld most provisions of the ACA, but 20 states filed a new lawsuit against the Obama-era health insurance law earlier this year. The new suit alleges that when Congress removed penalties for violating the individual mandate last year it made the rest of the law unworkable. 

“I am at a loss for words to explain how big of a deal this is,” Nicholas Bagley, a University of Michigan law professor and former Justice Department attorney, told USA Today.

“The Justice Department has an obligation to defend the law and it has refused to do so because it dislikes this particular law,” Bagley said, adding that the Trump Administration’s “dislike for the Affordable Care Act outweighed its respect for the rule of law.”

Ironically (or hypocritically), Bagley defends the Obama Administration’s decision to stop legal defense of the DOMA because President Obama disliked that particular law. “Refusing to defend a law that countenanced overt discrimination against a disfavored group is different from refusing to defend one that regulates health insurance,” Bagley wrote in March, “But that’s the thing about precedent. It can be stretched.”

The Trump Administration move does not mean that Obamacare will lose the lawsuit by default. As with the DOMA, the courts have approved private attorneys to step in for the DOJ. Axios notes that a group of Democratic attorneys is being allowed to defend the ACA in court.

The DOJ does not join with the states in the full lawsuit, but is arguing that the ACA’s provisions regarding pre-existing conditions should be invalidated. In a letter to Minority Leader Nancy Pelosi (D-Cal.), Attorney General Jeff Sessions said, “Otherwise individuals could wait until they become sick to purchase insurance, thus driving up premiums for everyone else.”

The future of the Obamacare lawsuit is uncertain. The makeup of the Supreme Court has not changed materially since the previous decisions upheld the law. A different outcome would most likely require Chief Justice John Roberts to change his vote.

The Trump Administration policy may also affect the midterm elections. A recent NBC News/Wall Street Journal poll found healthcare to be the top concern of registered voters. Voters have long favored protection for pre-existing conditions.

Having failed to reform or replace Obamacare, Republicans are now dependent upon the courts to kill the failed health insurance law. With Congress in a stalemate, both parties are increasingly looking to the courts to bypass the legislature and break stalemates. While this is not the role that the founders envisioned for the courts, if Democrats don’t like the Trump Administration’s decision, they have only Barack Obama to blame.

Originally published on the Resurgent

Health Care Frustrations Emerge As Election Issue

As health insurance companies set rates for 2019, the country is about to be reminded of one of President Trump’s biggest failures, the failure to repeal or reform Obamacare. Republicans made several attempts in 2017 to reform the Affordable Care Act, but failed to garner even the simple majority required to pass the measure under budget reconciliation rules. Now their inability to fix the law is coming home to roost in the form of higher insurance premiums for many Americans.

If you listened to President Trump last December, you might think that Obamacare was repealed. In reality, Republicans repealed the law’s individual mandate, but left most of the ACA intact. Repeal of the mandate might actually worsen the problem of rising premiums as young, healthy insureds flee from the expensive policies still mandated by Obamacare.

In March, the Wall Street Journal forecast that health insurance premiums would be an election issue after Congress failed to agree on a stabilization (i.e. subsidy) bill to shore up the individual health insurance markets. Now that forecast is starting to come to fruition as the first announcements of premium increases are being heard. Maryland, one of the first states for which information about the new insurance rates has become available, has insurers proposing an average increase of 32 percent. The proposed increases range from 18 to 91 percent.

Announcements of rate hikes, along with news of insurers withdrawing from Obamacare marketplaces, have become an annual tradition in the years since Obamacare was implemented, but rising health insurance costs don’t just affect those Americans on individual plans. Marketwatch recently reported on a study that showed that rising health insurance costs contribute to slower wage growth among the nation’s workers, many of whom are covered by group plans purchased by their employer. Group health insurance premiums were forecast to increase by about four percent for 2018.

Americans are getting less coverage despite paying higher premiums. Spending on deductibles and coinsurance, the patient’s share of medical bills, has increased in recent years as copayments have covered less. Whether you have an Obamacare plan or an employer-based plan, you are probably paying more out of your own pocket for health care than you were just a few years ago.

There are also hidden limitations that you only find out about when you have a claim. As an example, my wife had to go to the hospital in an ambulance last year. Six months after her hospital stay, we received a bill from the ambulance service asking us to pay more than $4,000 for a 30-minute ride. When I followed up with Blue Cross Blue Shield of Texas, our insurance company, I was told that the ambulance service was out-of-network. When I pressed further, I found that Blue Cross did not have any ambulance providers in their network in the entire state of Texas. As a result, Blue Cross paid less than $1,000 on a total claim of more than $5,000.

In the United States, the way that we buy health care is totally disconnected from markets and economic reality. If you have any idea what you will owe a doctor for something as simple as an office visit, you are in a minority of consumers. The problem is even worse if you go to the hospital for tests or surgery where several billing entities from the doctor to the anesthesiologist to pharmacies and labs and the hospital itself are involved. Prices are not known until after the service is provided. In many cases, the patient doesn’t even know what services are being provided or by whom.

In another personal experience, I went for a colonoscopy a few years ago. I discussed the cost of the procedure with the doctor and the hospital before I was admitted, but when the bills came later, it was more than three times what I had been told to expect. After months of running between the hospital, the doctor and the insurance company, I traced the problem to an error in the diagnostic code. It took many more hours on the phone to get this code corrected. Many patients probably simply pay incorrect medical bills without questioning whether they are correct or taking the time to investigate.

An accounts receivable representative for the ambulance service that we used told me that, because Blue Cross is hesitant to pay ambulance bills, they often send shockingly large bills to the patient. Part of the goal is to get the patient to put pressure on the insurance company to pay up. The provider doesn’t necessarily care where the money comes from as long as they get paid and the insurance company is happy if patients pay the bills and let them off the hook.

Because of the lack of competition in the healthcare system, Americans are left without options when health insurance companies misbehave. The majority of Americans who get their health insurance through an employer have no input into the choice of a health insurance provider. You can only decide whether to participate in or drop an employer health plan during open enrollment. If you decide to buy insurance from a company other than your group health provider, you lose the employer contribution to the premium. This means that you end up paying far more to buy your own health insurance that you would if you participated in the group plan.

The problem is similar for workers who like their company’s group health plan, but who leave their job. Coverage may not start at a new company for several weeks. In the meantime, health insurance premiums for your old plan may from a few hundred dollars to more than thousand.

Frustration with the existing health insurance system is probably a major reason why a majority of Americans now favor a single-payer system (i.e. government-run universal healthcare). Several recent polls have shown growing support for more government involvement in health care. In April, a Washington Post – Kaiser poll found that 51 percent of Americans favored single-payer. Gallup and Pew found similar results last year. The increasing costs and decreasing value of private health insurance is undoubtedly leading many Americans to embrace this radical idea.

Republicans have damaged themselves on the issue. The Republican health bills of 2017 were so unpopular that they turned public opinion around on Obamacare. After years of favoring repeal of the ACA, more Americans now oppose repeal than support it. CNN polling from March shows Democrats with a 20-point lead over Republicans when voters are asked which party would do a better job on health care, the largest gap of any issue.

At this point, there are no signs that Republicans are interested in fixing the health insurance problem. President Trump is basking in recent foreign policy successes, but Republicans may be hurt in the midterms if attention shifts to domestic issues like healthcare. Korean détente may mean that voters focus more on pocketbook issues instead of national security. If health insurance prices spike in October and November as Obamacare exchanges and employers hold open enrollment for 2019 health plans, it could provide Democrats with a much-needed issue with which to hammer Republicans.

Originally published on The Resurgent

Alexander Points Finger At Trump As Opposition to Obamacare Deal Mounts

Sen. Lamar Alexander’s (R-Tenn.) deal to stave off the collapse of Obamacare is meeting with a less than ecstatic response. As the bipartisan framework meets opposition, Alexander pointed to President Trump as the force behind the tentative agreement.

After a phone call with the president, Sen. Alexander claimed that the deal was Trump’s idea in the first place. “Trump completely engineered the plan that we announced yesterday,” Alexander told Mike Allen of Axios. Alexander said that Trump repeatedly called to push him toward a deal that included Sen. Patty Murray (D-Wash.). “He wanted a bipartisan bill for the short term,” Alexander said.

A few minutes after Alexander’s appearance with Allen, President Trump appeared to throw then senator under the bus. Trump tweeted, “I am supportive of Lamar as a person & also of the process, but I can never support bailing out ins co's who have made a fortune w/ O'Care.”

Meanwhile, there are signs that the deal may be a tough sell for Republicans. A spokesman for Speaker Paul Ryan said, “The speaker does not see anything that changes his view that the Senate should keep its focus on repeal and replace of Obamacare.”

Business Insider reported that Senator Orrin Hatch (R-Utah) had announced that he would oppose the Obamacare deal. Hatch, who penned an op-ed in the Washington Post entitled, “Obamacare doesn’t deserve a bailout,” told reporters, “It would last two years and spend a whopping amount of money and not solve the problem.” John Thune (R-S.D.), the Senate’s third highest ranking Republican, said that the bill had “stalled out.”

The effort did pick up several cosponsors as Senators Bob Corker (R-Tenn.), John McCain (R-Ariz.) and Susan Collins (R-Maine) signed on to the bill. There were reports that more cosponsors from both parties would announce their support soon.

The bill could pass with combined support of Republicans and Democrats, even if a large number of conservatives withhold their support. Small Republican majorities in both houses make it difficult to pass a unilateral bill. Republicans alone do not have the numbers to win a cloture vote in the Senate and the loss of only three senators is enough to scuttle a budget resolution that requires only a simple majority to pass. However, a bipartisan coalition could conceivably muster enough support to win a vote as well as end a filibuster by holdouts.

At this point, Majority Leader Mitch McConnell (R-Ky.) has not indicated his position on the deal. As leader of the Senate, McConnell could doom the bill by preventing the Senate from bringing it to a vote.  

If the bill dies, the Trump Administration has announced that it will suspend Obamacare subsidy payments to insurance companies in accordance with a federal court decision earlier this year. The effect that this would have upon insurance markets is uncertain, but insurance company stocks tumbled after the president announced the decision.

Sen. Alexander said that Republicans may reintroduce the Graham-Cassidy bill if the Alexander-Murray deal fails. Graham-Cassidy was withdrawn last month after four Republican senators announced that they would vote against it.  

Originally published on The Resurgent

Bipartisan Deal Would Preserve Obamacare For Two Years

In an “if you can’t beat them, join them” moment, Republicans appear to have reached a deal with Democrats to preserve key components of the Affordable Care Act in the wake of President Trump’s announcement that his administration will stop paying subsidies to insurance companies under the Obama-era law. The tentative agreement was announced by Senators Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) on Tuesday.

“Sen. Murray and I have an agreement. We're going to round up co-sponsors as best we can,” Alexander told Politico.

President Trump appeared optimistic about the deal. “Lamar has been working very, very hard with the Democratic, his colleagues on the other side,” Trump said. “And they're coming up and they're fairly close to a short-term solution. The solution will be for about a year or two years. And it’ll get us over this intermediate hump.”

The deal reportedly contains funding for Obamacare’s subsidies to insurance companies for 2017, 2018 and 2019 as well as funding for state Obamacare enrollments. In return, Republicans would get expanded access to state waivers to approve lower cost plans and consumers over 30 would be allowed to purchase “copper plans” that cover only catastrophic illnesses for a lower premium, but have higher out-of-pocket costs.

There would also be an important advantage for Republicans in postponing the shakeout of the insurance industry that would accompany stopping the subsidy payments. No one knows precisely what would happen if the Trump Administration stopped the payments, but the likely chaos in insurance markets would probably not reflect well on Republicans as midterm elections approach. The deal would give Congress two additional years to resolve the issue.

Whether the bill can pass Congress is uncertain. Chairman of the House Republican Study Committee, Rep. Mark Walker (R-N.C.) tweeted, “The GOP should focus on repealing and replacing Obamacare, not trying to save it. This bailout is unacceptable.” Others, such as Sen. Ted Cruz (R-Texas), adopted a wait and see attitude.

“Most of the members of the conference are finding out about the details for the first time. I don’t think anybody beyond Lamar and a few others know,” Sen. John Kennedy (R-La.) said. “The details are important.”

Senate Minority Leader Chuck Schumer (D-N.Y.) seemed to favor the bill. “We think it's a good solution and it got broad support when Patty and I talked about it with the caucus,” he said. “We've achieved stability if this agreement becomes law.”

If Schumer and Nancy Pelosi (D-Cal.) can deliver Democrat votes, the bill could become law in spite of almost certain opposition by conservative Republicans. At this point, it seems likely that Democrats would favor the bill, which would preserve most of Obamacare intact and force the Trump Administration to continue paying subsidies.

At this point, there is no indication of how fast the bill will move through Congress. Majority Leader Mitch McConnell (R-Ky.) said, “We haven't had a chance to think about the way forward yet.” Speaker of the House Paul Ryan (R-Wisc.) has not publicly addressed the new deal, but told the Milwaukee Journal-Sentinel on Monday that he preferred a comprehensive approach to replacing the Affordable Care Act.

“I think we’ve got to do more to get it fixed, but the answer is not to shovel more money at a failing program that is doubling premiums and causing monopolies,” Ryan said. “The answer is to reform the underlying failure of the law and one of those underlying failures is the lack of choice and competition in health insurance.”

Originally published on The Resurgent

Is Trump's Obamacare Executive Order Constitutional?

There has been a lot of discussion about President Trump’s healthcare Executive Order. Most of the discussion centers around the likely effects of the order while little has been said about the constitutionality of Trump’s executive action. For a party that roundly condemned President Obama’s abuse of executive authority, a big question should be whether Trump has the legal authority to make the changes that he proposes.

The bottom line is that Trump’s Executive Order doesn’t actually make any changes to the Affordable Care Act. What it does do is to order cabinet secretaries to “consider proposing regulations or revising guidance, consistent with law.” In other words, Trump isn’t proposing changes to laws passed by Congress, he is considering changes to regulatory laws enacted by bureaucrats. These changes will be “considered” in three main areas.

First, the president wants to expand access to association health plans (AHPs). Health Affairs notes that these plans are more loosely regulated than traditional insurance plans. They are normally regulated by the states, but can be regulated by the federal government in the case of some national associations. The order instructs the Secretary of Labor to “consider” expanding the definition of “employer” under ERISA to allow more groups to sell AHPs and to “promote AHP formation on the basis of common geography or industry.” To purchase insurance, consumers would have to be a member of the association.

Second, the Executive Order moves to expand Short-Term, Limited-Duration Insurance (STLDI) policies. The order notes that STLDIs are “exempt from the onerous and expensive insurance mandates and regulations” of the Affordable Care Act, but that “the previous administration took steps to restrict access to this market by reducing the allowable coverage period” to less than three months. “To the extent permitted by law and supported by sound policy,” the president directs cabinet members to “consider allowing such insurance to cover longer periods and be renewed by the consumer.”

STLDIs are not considered to be individual health insurance policies and do not fall under the insurance policy requirements of the Affordable Care Act. The policies are governed by rulemaking agencies of the Department of the Treasury, Department of Labor, and Department of Health and Human Services. Therefore, these departments can amend the rules for STLDIs without going through Congress.

Third, the Executive Order instructs relevant cabinet secretaries to “consider proposing regulations or revising guidance, to the extent permitted by law and supported by sound policy, to increase the usability of HRAs, to expand employers' ability to offer HRAs to their employees, and to allow HRAs to be used in conjunction with nongroup coverage.”

HRAs are health reimbursement accounts. They allow employers to contribute money on a pre-tax basis to reimburse employees for health insurance premiums and out-of-pocket expenses. HRAs were created by Congress, but executive branch agencies have leeway in how to regulate them.

President Trump’s decision to halt Obamacare subsidies to insurance companies is not part of the Executive Order, but is on firm legal ground. House Republicans sued the Obama Administration over the subsidies in 2014. In May 2016, a federal judge ruled that Congress had authorized the payments, but had never appropriated money for them. The Obama Administration appealed the ruling, but the decision by President Trump seems to be merely accepting the court’s initial decision.

This doesn’t mean that the Trump Administration will be able to stop making the payments. Several states ultimately joined the appeal, claiming that the Trump Administration was not adequately defending their interests. Now 18 states have filed a new lawsuit seeking an injunction against President Trump’s decision.

Because the President Trump’s Executive Order does not change existing law and only instructs cabinet members to “consider” making changes to bureaucratic regulations within the framework of the law, the order is constitutional. It remains to be seen what regulatory changes the various cabinet secretaries will propose, but the changes will probably be much less sweeping than claimed by either right or left-wing pundits.

President Trump’s Executive Order is legal in large part because it doesn’t do much. The president simply does not have much authority to change laws that have been passed by Congress. The decision to stop insurance company subsidies is a more serious threat to Obamacare, but even this is unlikely to take effect until the lawsuit by the states is settled. 

Originally published on The Resurgent

Trump Administration to End Obama's Contraception Mandate

One of the most egregious examples of a federal attack on religious liberty in recent years may be about to come to an end. There are reports that the Trump Administration is preparing new regulations that will end the birth control mandate established by the Obama Administration as part of the Affordable Care Act.

The New York Times reports that new rules, which could be issued on Friday, would offer exemptions to certain employers who have moral objections to providing insurance that includes contraceptives to their employees. The new rules would reportedly cover employers and insurers who hold “sincerely held religious beliefs” or “moral convictions” against providing contraception.

The mandate was not part of the ACA, but was the product of regulations by the Department of Health and Human Services. While the Obama Administration did provide a religious exemption from the rules, Cardinal Daniel Dinardo noted in 2011, “Jesus himself, or the Good Samaritan of his famous parable, would not qualify as ‘religious enough’ for the exemption….”

Many private employers also objected to the fact that the regulation required them to purchase insurance for their employees that included not only contraceptives, but drugs that induce abortions. Others, such as employers who are Catholic, objected to contraception in general.

The mandate prompted several lawsuits. The Little Sisters of the Poor, a Catholic religious charity made of nuns who practice celibacy, went to the Supreme Court to seek relief from the mandate. In 2015, Hobby Lobby won its lawsuit and the government was forced to amend its rule to provide religious exemptions. In the final rule, insurers were still forced to provide coverage for these employees, but the employers were not billed for the contraceptive coverage.

President Trump promised to end the revised mandate during the campaign, but so far has not taken steps to do so. In August, Daniel Dinardo, now the Catholic Archbishop of Galveston-Houston, wrote an op-ed in The Hill asking why the Obama-era policy was still in place.

It is important to note that changing the contraception mandate will not ban contraception in any way. It would merely mean that employers would not be forced to pay for drugs that they find morally objectionable. Their employees will still be able to get birth control and abortifacient prescriptions, they would just have to bear the cost, about $50 per month, on their own.

If President Trump does decide to roll back the Obama-era mandate, he will have fulfilled an important part of his promise to protect religious liberty and freedom of conscience. The big question is why he waited so long to do so.

Originally published on The Resurgent

Republican Senators Try a 'Hail Mary' On Obamacare

After their embarrassing failure to repeal and replace Obamacare over the summer, Republicans in the Senate are gearing up for a “Hail Mary” attempt to at least make a modicum of reforms to the health care law. The Senate, where the previous attempt to rein in Obamacare died, may vote on the last-gasp effort by the end of September.

As explained previously in The Resurgent, Republicans cannot fully repeal Obamacare without 60 votes. The previous attempt at reforming Obamacare fell apart over details of how the law’s subsidies should be treated and how to handle medical care for the uninsured. Moderate Republican support for the ACA’s expansion of Medicaid also caused serious problems in crafting a replacement bill.

The new bill, written by Senators Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.), is much more modest than the failed American Healthcare Act. The proposal doesn’t completely repeal Obamacare, but does replace Obamacare’s tax subsidies with state block grants, repeals the individual mandate and scales back the Medicaid expansion.

“It's basically federalism where you just block grant the whole thing,” Speaker Paul Ryan (R-Wisc.) told the Washington Examiner. “You block grant Obamacare back to the states. Just the whole thing.”

Majority Leader Mitch McConnell (R-Ky.) has indicated that he will bring the bill to the floor for a vote if at least 50 of the 52 Republican senators support it. At the moment, the bill is short of that mark, but Politico reports that it is gaining steam after Graham publicly lobbied President Trump and others. Estimates put Republican support for the bill at 48 or 49 senators.

The bill appears to be on a fast-track. The Washington Post reports that Republicans have already submitted it to the Congressional Budget Office for analysis. If the bill is not passed before the end of September, the Post notes that the authority to pass the legislation with a simple majority under budget reconciliation rules would expire. This would effectively kill any attempts to reform Obamacare until next year.

If the bill does pass the Senate, it faces an uncertain future in the House of Representatives. The previous bill, which originated in the House, had to be finely tuned to pass by a slim majority. Under budget reconciliation rules, the House would have to pass the Graham-Cassidy bill with no changes.

No Democrats are expected to support the bill. Sen. Elizabeth Warren (D-Mass.) tweeted, “The Graham-Cassidy @SenateGOP ‘health care’ bill IS Trumpcare, & it will rip health care away from millions of Americans.”

As with the previous Obamacare reform bill, opposition to the bill is expected to come from the right as well as the left. Senator Rand Paul (R-Ky.) has announced that he will oppose the bill, calling it “Obamacare lite.” If Paul stands firm, the defection of any other Republican will doom the bill.

Paul’s stance against “Obamacare lite” begs the question of whether he and the Freedom Caucus would prefer the full version of Obamacare to an imperfect Republican reform bill. For the foreseeable future, those are the only two options. 

Originally published on The Resurgent

Republican Senators Say Health Bill is Dead

John McCain (R-Ariz.) and other Republican senators are saying what everybody seems to already know about the Republican repeal/reform-and-replace effort. After eight years of campaigning to repeal Obamacare, it increasingly seems that the Republican effort is about to die within sight of its goal.

“I think my view is it's probably going to be dead,” McCain said on “Face The Nation,” adding, “but I am- I've been wrong.”

McCain said that if the current bill fails, Republicans should try again with a bill that aims to win some Democrat votes. “Introduce a bill,” McCain said. “Say to the Democrats, ‘Here's a bill.’ It doesn't mean they control it. It means they can have amendments considered. And even when they lose, then they're part of the process. That's what democracy is supposed to be all about.”

The close margins in the Senate, 52 Republicans to 48 Democrats, mean that, unless some Democrats cross the aisle to vote for the Republican bill, the GOP can only lose two votes and still be able to pass the bill. The GOP health plan has come under fire from moderates like Lisa Murkowski (R-Alaska) and Susan Collins (R-Maine) as well as from conservatives like Ted Cruz (R-Texas) and Mike Lee (R-Utah).

Senator Bill Cassidy (R-La.) agreed with McCain’s assessment on “Fox News Sunday.” “Clearly, the draft plan is dead,” Cassidy said, “but we don't know what's in the serious rewrite” of the bill.

Even Senate Majority Leader Mitch McConnell (R-Ky.) admitted the bleak future of the bill. McConnell said that, while he isn’t giving up on repeal, Republicans may need to work with Democrats on a short-term fix for Obamacare.

President Trump and other Republicans from Ben Sasse (R-Neb.) to Rand Paul (R-Ky.) have called upon congressional Republicans to simply repeal Obamacare if they cannot agree on a replacement. A repeal bill would face the additional hurdle of a cloture vote that would require 60 votes for passage.

Sasse suggests a new version of the 2015 Obamacare reconciliation bill. Unless Collins, Murkowski and other GOP holdouts on the Medicaid expansion reverse themselves, this bill would also fall short of even a simple majority.

Without a change of heart from either the Republican moderate or conservative wing, the effort to repeal or reform Obamacare seems to be reaching a dead end. While the future of health insurance in America is uncertain, it is certain that the Republican base would view a failure to repeal Obamacare as the betrayal of a core promise.

The failure to reform Obamacare while they have the opportunity, the single most visible goal of the Republican Party for most of the past decade, could rip the party apart. 

Originally published on The Resurgent

Sasse, Paul, and Trump Call For Obamacare Repeal Instead of Reform

In statements echoed by President Trump on Twitter, two prominent Republican senators have called for the GOP to skip the health care overhaul and focus on simple repeal of Obamacare if Republican Senate leadership cannot find 50 votes to move the current health care reform bill forward. Earlier this week, Majority Leader Mitch McConnell (R-Ky.) announced that a vote on the health care bill would be delayed until after the July 4 recess.

In a letter to the White House quoted in the Wall Street Journal, Sen. Ben Sasse (R-Neb.) said, “On the current path it looks like Republicans will either fail to pass any meaningful bill at all, or will instead pass a bill that looks to prop up many of the crumbling Obama care structures.”

“We must keep our word,” Sasse continued. “Therefore, if on July 10 we don’t have agreement on a combined repeal and replace plan, we should immediately vote again on... the December 2015 Obamacare repeal legislation that the Congress passed but President Obama vetoed.”

Within a few minutes of Sen. Sasse’s discussion of re-introducing the 2015 bill, HR 3762, President Trump tweeted support for the idea. “If Republican Senators are unable to pass what they are working on now, they should immediately REPEAL, and then REPLACE at a later date!” Trump said on Twitter.

If Republican Senators are unable to pass what they are working on now, they should immediately REPEAL, and then REPLACE at a later date!

— Donald J. Trump (@realDonaldTrump) June 30, 2017

Sen. Rand Paul (R-Ky.) also endorsed the idea. “I have spoken to @realDonaldTrump & Senate leadership about this and agree. Let's keep our word to repeal then work on replacing right away,” Paul tweeted.

I have spoken to @realDonaldTrump & Senate leadership about this and agree. Let's keep our word to repeal then work on replacing right away.

— Senator Rand Paul (@RandPaul) June 30, 2017

The 2015 bill in question, HR 3762, was not technically a full repeal of Obamacare either since it also amended the Affordable Care Act rather than repealing it outright. A full repeal would require 60 votes for cloture in the Senate, which is far out of reach. The bill passed the Senate in a largely party line vote on December 3, 2015 by a 52-47 margin.

Sasse has not suggested a strategy for passing a 2017 version of the bill. The problem for Republicans on passage of the current health care reform bill is that nine Republican senators are reportedly in opposition to the bill. Assuming no Democrats cross the aisle, Republicans could lose no more than two senators and still be able to pass the bill.

The current Republican opposition to the health care reform is from both the center and the right wings of the GOP. Moderate Republicans such as Susan Collins (R-Maine) and Rob Portman (R-Ohio) argue that the bill hurts too many people on Medicaid in their states while conservatives such as Ted Cruz (R-Texas) and Mike Lee (R-Utah) say that the bill does not go far enough in reforming Obamacare. With eroding support from both ends of Republican political spectrum, the current bill has little chance of passage.

Sasse’s plan to revive the 2015 bill is a partial answer in that it should bring the conservatives back on board. The problem is that Republicans would still need moderate votes to move the bill forward.

When the bill originally passed in 2015, Republicans held two more seats in the Senate than they do today. Back then, two Republicans crossed party lines to vote against the bill: Susan Collins and Mark Kirk (R-Ill.). Kirk lost his seat to Democrat Tammy Duckworth in 2016, but Collins is still in the Senate and could be counted on to vote against the bill once again. That leaves Republicans with a one vote margin.

Earlier this year, The Resurgent reported that four Republican senators who had voted for the 2015 bill would refuse to vote for a bill that did not allow a slow phase out of the Obamacare Medicaid expansion. If Shelly Moore-Capito (R-W.V.), Rob Portman (R-Ohio), Corey Gardner (R-Col.) and Lisa Murkowski (R-Alaska) stick to their pledge, it would doom Sasse’s plan.

Still, a deficit of five votes is a more surmountable obstacle than the deficit of nine votes that the GOP currently faces. It is possible that pressure could be brought to bear on the four senators who previously voted for the bill that would keep them in the “yes” column.

An additional risk would be with the reform that still must come after the passage of the near-repeal. Democrats might be persuaded to join the reform effort if most of Obamacare was gutted, but they might also adopt a you-break-it-you-bought-it policy that would allow them to campaign against the Republican-created chaos in the health care markets in 2018 and beyond. Given recent Democrat obstructionism, there is little doubt which course they would take.

Still, as the Republican health care reform seems increasingly dead in the water, Sasse’s plan, long shot that it is, may be the only viable option to keep the GOP promise to repeal and replace Obamacare. 

Originally published on The Resurgent

Obamacare Reform Is Looking Doubtful This Year

If you’re wondering whatever happened to the Republican health care reform bill, you are not alone. When we last heard from the American Health Care Act, House Republican leaders were waiting on the Congressional Budget Office to score the bill before submitting the legislation passed in the House to the Senate. The CBO scored the bill in late May, but the silence from the Republican ranks has been deafening. The congressional website does not show any action on the bill since it passed the House on May 4.

Readers of The Resurgent are aware that the Republican health care bill falls short of full repeal. Senate rules require 60 votes for cloture on a repeal bill and Republicans would not be able to find eight Democrats to join them in ending a Democrat filibuster. Even if Republicans eliminated the filibuster entirely, they would not have enough votes for full repeal because at least four Republicans have pledged to oppose a repeal bill that does not provide for a phase out of the Obamacare Medicaid expansion.

Now some Republicans are saying that it is doubtful that they will be able to pass even an incomplete health care reform bill. “I don’t see a comprehensive health care plan this year,” Senator Richard Burr (R-N.C.) said in Politico. “It’s unlikely that we will get a health care deal, which means that most of my time has been spent trying to figure out solutions to Iowa losing all of its insurers.” Burr serves on the Senate Heath, Education, Labor and Pensions Committee.

In the Wisconsin State Journal, Senator Ron Johnson (R-Wisc.) agreed that the first priority to would probably be to act to preserve the health insurance markets in their current form. Johnson said that a short-term “market stabilization” bill could be passed that would fund the Obamacare exchanges with billions of dollars to help prevent insurers from exiting the marketplaces. Such an approach would reduce volatility in the Obamacare markets and buy time for Republicans to agree on a reform bill.

“To me, this may be a two-part process. I would admit that’s probably a minority view in the Republican Senate right now,” Johnson said.

Senator Jeff Flake (R-Ariz.) also tried to tamp down expectations. “There are some still saying that we’ll vote before the August break,” he told the Washington Post. “I have a hard time believing that.”

The fundamental problem is that conservative and moderate Republicans do not agree how to handle various aspects of the health care issue. Although Republicans have been united in their desire to repeal and replace Obamacare since the day it was passed, they disagree on the details of what should come next.

In the eight years since Obamacare became law, Republicans such as Tom Price, formerly a Georgia congressman and now Secretary of Health and Human Services, have written legislation to repeal Obamacare and reform the health insurance industry, but the party has not coalesced around any single bill. When Donald Trump eked out a squeaker of a victory in the Electoral College, Republicans were caught flat-footed and did not have a plan for how to exploit his victory. Indications were that, as late as early February, Republicans had not even started writing an Obamacare reform bill. The Senate considers the House bill dead on arrival and is writing its own version of health care reform, which may be available as early as this week.

President Trump’s antics are also hurting the possibility of passing a health care bill. The investigation into the Trump campaign’s possible connections with Russia and the firing of FBI Director James Comey are distractions that make it even more difficult to find a compromise that is acceptable to all GOP factions. The president showed leadership in the fight to pass the AHCA in the House, but has largely been missing-in-action on the issue in the month since the House vote.

Not all Republicans are pessimistic on health care. Senator John Cornyn (R-Texas) was quoted in The Hill as saying, “We do need to take care of our business, and I think you mentioned healthcare, and that's certainly front and center in the United States Senate — something we're going to have to get resolved here in the next few weeks.” Cornyn said that he thought a Senate bill would be “done by the end of July at the latest.”

Repeal of Obamacare has been the centerpiece of the Republican platform since 2010. The fact that repeal is not possible, even with Republican majorities in Congress and a Republican president, is not going to please most Republican voters. If the new Republican administration leaves Obamacare completely intact, it may well face a mutiny from the grass roots.

 Originally published on The Resurgent

New Cruz? Texas Senator Works For Health Care Compromise

Texas Senator Ted Cruz has developed a reputation as a firebrand. Cruz has made refusal to compromise a trademark of his career in Congress and has often had strong words for fellow Republicans who disagreed with him on strategy. Now a new behind-the-scenes report by the Wall Street Journal reports that Cruz may be turning over a new leaf.

The Journal reports that Cruz began working quietly with moderate Republicans to find a consensus on health care reform that has a realistic chance of becoming law. Cruz was instrumental in forming a working group of 13 Senators that had its origin in a February steak dinner with Sen. Lamar Alexander (R-Tenn.). The group includes Republicans concerned about the effect of an outright repeal of Obamacare’s Medicaid expansion and pre-existing conditions rules such as Rob Portman (R-Ohio), Tom Cotton (R-Ark.), Cory Gardner (R-Col.) and Mike Lee (R-Utah). Cruz has reportedly been working with House Freedom Caucus Chairman Mike Meadows (R-N.C.) for the past month.

Senators on both sides of the aisle expressed surprise at Cruz’s new strategy. “It’s a ‘you live long enough, anything can happen’ moment,” said Lindsey Graham (R-S.C.).

“It would be a first for Sen. Cruz,” noted Chris Murphy (D-Conn.).

The GOP’s 52-vote majority in the Senate means that Republicans can lose no more than two votes and still be able to pass an Obamacare replacement. A defection of two Republicans would require Vice President Mike Pence to cast the tie-breaking vote. At least five Republican moderates are considered to be doubtful in their support for the American Health Care Act.

The working group is expected to be vital in bringing various Republican factions in the Senate together to forge a compromise that can replace as much of Obamacare as possible. Cruz’s participation and support may help bring other conservatives such as Mike Lee and Rand Paul (R-Ky.) on board with the Republican reform effort.

In the past, Cruz has had difficulty with consensus building and passing legislation. He is perhaps most well-known for his role in the 2013 government shutdown and attempt to defund Obamacare. With Republicans outnumbered by Democrats, the shutdown failed to halt the implementation of President Obama’s namesake health bill. Cruz was also known for failed attempts to prevent an increase in the debt ceiling and compromise spending bills under the Obama Administration.

Cruz may be realizing that the role of majority party senator is very different from that of one who serves in the opposition. When a party is in power, it is expected to deliver results in the form of advancing its legislative agenda. It is not enough to just say “no” when your party controls both houses of Congress and the White House.

“They’re giving him a leadership role and he’s going to have to make the most of if it,” said Rick Tyler, who served with Cruz’s presidential campaign. “If he can pull it off it’s a huge victory. But it’s fraught with danger.”

The upside for Cruz would be an enormous amount of prestige and notoriety if he shows an ability to build a coalition to pass a landmark reform bill. The boost for Cruz could potentially reach beyond his normal conservative base and lay the groundwork for a second presidential campaign in 2020.

Without the support of Cruz and other Senate conservatives, a reform effort would necessarily have to reach across the aisle to Senate Democrats. That would mean fewer conservative reforms in a watered-down bill. The alternative would be to delay reform until after the 2018 elections or until health insurance markets become so dysfunctional that the public demands action.

A potential pitfall would be alienating the conservative base whose expectations are for a full repeal of Obamacare. Even though Republicans do not have the votes for a full repeal, Mr. Cruz has helped stoke those expectations over the past few years. Many conservatives view anything short of full repeal to be a betrayal. Cruz must help the party overcome that view and sell the reform bill to the conservative base.

Health care reform gives Ted Cruz an opportunity to break out of his stereotypical role as a roadblock in the Senate. If Cruz can prove that he has the ability reach out and build a working majority with senators who don’t share his views, it would represent a major milestone in his career make him an even greater force in the Senate.

Originally published on The Resurgent

AHCA is best chance to replace Obamacare in our lifetime

The House of Representatives finally passed a bill to gut Obamacare and many conservatives are upset. Admittedly the bill is not full repeal. It is far from perfect. If I was going to write a health care reform plan, the American Health Care Act would not be it. Still, I’m very glad that the House passed the bill and I fervently hope that the Senate moves the legislation forward. Why? Because it is the only health care reform that has any chance of passing.

Many myths have grown up around Obamacare and the Republican repeal and replace effort. Over time, we have forgotten that Obamacare was not passed by a budget reconciliation. “HR 3590, the Patient Protection and Affordable Care Act,” was passed on Christmas Eve 2009 after a cloture vote by 60 Democrats ended a Republican filibuster. It was a traditional bill that requires a traditional bill to repeal.

So, what was the controversy about the budget reconciliation? After Scott Brown (R-Mass.) was elected to the Senate, the Democrats could no longer break Republican filibusters. If the Democrat-controlled House amended the ACA, it would be subject to another cloture vote, which the Democrats would lose. The answer was to have the House pass the bill unchanged and use the budget reconciliation process to pass a second bill, “HR 4872, The Healthcare and Education Reconciliation Act,” by a simple majority vote. This bill was subject to the same limitations that the GOP now faces in passing their own budget reconciliation.

Even though Republicans hold the presidency and control both houses of Congress, they were not granted a blank check by voters. A full repeal would require 60 votes for cloture in the Senate and there are only 52 Republicans. The mathematical problem is obvious.

But what about the 2015 repeal bill that was vetoed by President Obama, you may ask. Republicans didn’t have 60 votes in 2015 either, but they passed a repeal bill then. Why can’t they do it now?

The answer is that the 2015 repeal bill was not a full repeal either. The 2015 bill, was also a reconciliation bill that carried the unwieldy title, “HR 3762 To Provide for Reconciliation Pursuant to Section 2002 of the Concurrent Resolution on the Budget for Fiscal Year 2016.” The text of the bill states in Section 102 that the ACA “is amended,” not repealed.

If the 2015 bill was better that the AHCA of 2017, it is for two reasons. First, there were 54 Republicans in the 114^th Congress where there are only 52 now. The GOP could afford to lose more votes in the Senate in 2015 that it can today.

Second, four Republican senators who voted for the 2015 bill now say that they won’t vote for a bill that does not provide for a phase out of the Medicaid expansion. Sens. Rob Portman (Ohio,) Shelley Moore Capito (W.Va.), Cory Gardner (Colo.) and Lisa Murkowski (Alaska) refuse to back the same bill that they voted for two years ago. Sen. Susan Collins (R-Maine) voted against the 2015 bill and would presumably do so again. Other Republicans are reluctant to repeal the popular provision concerning pre-existing conditions. It is these five senators and House moderates, not the Republican leadership or President Trump that are forcing a more watered-down version of the bill.

Some conservatives suggest that Republicans should get rid of the filibuster to pass a repeal. We wouldn’t need 60 votes then and the Democrats will probably kill it anyway the next time they have a majority, they argue.

The problem with this strategy is that full repeal could not even win a simple majority vote. The five Republican defectors in the Congress and the Tuesday Group of 50 Republican moderates in the House would kill it.

Removing the filibuster would also mean that Democrats would only need simple majorities to replace Republican health care reform with a national single-payer system the next time they control both houses of Congress and the presidency. It would also usher in a host of other bad ideas from gun control to a higher minimum wage to higher taxes to onerous regulations on practically everything. It is true that Democrats might one day choose to remove the filibuster, but it is certain that if Republicans remove it now, for no strategic reason, Democrats will have a field day when they return to power.

What, then, are the options for Republicans on Obamacare? One option is to wait and hope for a filibuster-proof majority. If you favor this option, be aware that the last time that Republicans had a 60-vote majority was the 61^st Congress from 1909 to 1911. It is extremely likely that before the Republicans get a supermajority, Obamacare will implode, health insurance premiums will skyrocket, insurance companies will cancel policies and hell will freeze over. I have little doubt that if Republicans hold out for the perfect, full repeal bill that I will die of old age with Obamacare still intact. (I’m only 45.)

Waiting until 2018 might give the Republicans a few more votes to craft a better compromise. It is also possible that two years into the Trump Administration, voters might deliver a rebuke to Republicans in the form of Democrat majority in either the House or Senate that makes any sort of conservative impossible. In any event, it is doubtful that the numbers would change enough in the GOP’s favor to justify putting off a cornerstone promise of the campaign for two years. The longer Republicans wait to take action, the more entrenched Obamacare will become.

A better option is to take baby steps toward the full repeal of Obamacare starting now with the AHCA. The current bill has the support of moderates as well as the Freedom Caucus and has decent chance of becoming law. While far from ideal, it is a reasonable bill that can hopefully be improved further in its journey through the Senate. Even if it became law in its current form it would mark a vast improvement over Obamacare.

The Republican reform bill should not be viewed as a final step, but as a first step toward total repeal. Without a supermajority, it may take years of nibbling at the edges of Obamacare to fully repeal the behemoth, but conservatives have to start somewhere. The logical place to start is the bill that has the support of the two disparate factions of the GOP. The only bill that has a chance of becoming law.

Conservatives must decide whether it is worth trading a chance to gut Obamacare now to wait for a perfect bill in the distant future. The answer should be obvious. We should not allow the perfect to be the enemy of good and the possible.

Seize the day and start saving American healthcare!

Originally published by The Resurgent