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

House may have to vote on health care bill again

If you are wondering why the Senate hasn’t started working on the American Health Care Act two weeks after the House passed the bill, you aren’t alone. Bloomberg reports that the measure is stalled with the House leadership after being approved by a four-vote margin earlier this month.

According to Bloomberg, the holdup is a series of last minute amendments that were made before the vote in order to garner more support. The late changes have not been scored by the Congressional Budget Office and Republican leaders are waiting for the CBO numbers before sending the bill to the Senate.

If the CBO numbers don’t show at least $2 billion reduction in the deficit, it would doom the bill in the Senate because it would not qualify for the budget reconciliation process that avoids a Democrat filibuster. The GOP would be forced to start the process again with a new budget resolution in the House. Before the changes, the bill was projected to save about $150 billion over 10 years.

“We’ve got to wait for the CBO score to prove that you meet the reconciliation test,” said Rep. Greg Walden (R-Oreg.), chairman of the House Energy and Commerce Committee.

A Republican aide told Business Insider that Republicans expected positive results from the CBO, but were waiting for the report to be sure. “Based on the previous two scores, we believe we'll hit our target deficit reduction number but we're holding out of an abundance of caution,” the aide said.

If the House has to vote on the bill again, passage would not be a slam dunk. In the first vote, 20 Republicans joined every House Democrat in voting against the bill. The current version of the bill was specifically crafted to gain enough support from disparate Republican factions to pass. If the bill has to be changed to satisfy budget reconciliation requirements, the fragile balancing act may be upset and changes may cost too many Republican votes to pass the bill a second time.

The CBO report is expected next week. 

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

Red state Republican deserts GOP on Obamacare

In a surprise announcement that underscores the difficulty that Republicans are having in assembling a majority to replace Obamacare, a Republican congressman from the red state of Missouri has announced that he will not support the current health care reform bill. After supporting earlier versions, Rep. Billy Long (R-Mo.) has become the latest conservative to jump ship and oppose the Republican effort to scuttle Obamacare.

Long represents Missouri’s seventh congressional district, a deep red district in the southwest corner of the state that includes Branson and Springfield. The district has been represented by a Republican since 1961. Voters there supported Donald Trump by a 70-25 percent margin over Hillary Clinton. Trump’s margin there was larger than that of any Republican presidential candidate this century. Long won both the 2016 primary and general election with more than 60 percent of the vote.

The conservative nature of Long’s district makes it all the more surprising that he would not be on board the Obamacare replacement effort. According to a statement by Long in Politico, it came down to how the Republican bill dealt with pre-existing conditions.

“I have always stated that one of the few good things about Obamacare is that people with pre-existing conditions would be covered,” Long said. “The MacArthur amendment strips away any guarantee that pre-existing conditions would be covered and affordable.”

The MacArthur amendment is a compromise reached between Rep. Tom MacArthur (R-N.J.) and Freedom Caucus Chairman Mark Meadows (R-N.C.). The amendment would allow states to seek waivers for several provisions of Obamacare such as benefits that are required to be covered under the law and the ban on allowing companies to charge more based on a person’s health history.

MacArthur told CNN that the plan would protect people with pre-existing conditions while giving states more flexibility. “We need to protect the most vulnerable people in the current plan. These are people with pre-existing conditions,” he said. “We want to make sure they are protected. Secondly, we have to give the states flexibility to bring premiums down for everyone else.”

Long’s opposition to the amendment underscores the difficulty that Republican leaders have in finding a balance between moderate and conservative viewpoints on healthcare. Like Long, even many Republican voters who have favor repeal of Obamacare find parts of the law attractive.

One of the most popular aspects of the health law is the provision that requires insurance companies to cover people with pre-existing conditions. A CNN/ORC poll from March found that 87 percent of voters favor “maintaining the protections offered to people with pre-existing conditions under Obamacare.” The numbers are unchanged across the political spectrum with 87 percent of Republicans and 85 percent of conservatives agreeing with the statement.

Such overwhelming opposition explains why so many Republican congressmen are reluctant to get on board with conservative plans to eliminate the requirement to cover pre-existing conditions. With a lifetime American Conservative Union rating of 91 percent, Long is no moderate or squish. A member of the House of Representatives since 2011, Long has undoubtedly learned to listen to constituents and is most likely hearing from many of them that they want pre-existing conditions covered.

The economic difficulty is that there is no free lunch. If pre-existing conditions are covered, many people won’t buy health insurance until they get sick. If people only buy insurance when they are sick, the cost of coverage goes up.

The Republican difficulty is that the free market position held by many conservatives is that the government should not mandate that insurance companies cover pre-existing conditions. This conflicts with the popular opinion of voters that people with pre-existing conditions should not be denied health insurance. The conflict has caused a schism in the party between those, often from safe Republican districts, who favor free market policies and those who are listening to the majority of voters.

There is also a time factor. Republicans lack the 60-vote majority in the Senate to avoid a filibuster so they are relying on the budget reconciliation process to pass their health care reform. If they cannot get agreement on health care, the budget reconciliation opportunity will vanish for another year.

The conundrum is similar to the one that Democrats faced in 2010 when they passed the Affordable Care Act. Poll after poll showed that voters opposed the Democrat version of health care reform. A CNN/Opinion Research poll taken just before the bill’s passage found that 59 percent opposed Obamacare. Democrats forged ahead against public opinion and paid for their arrogance with the loss of the House, the Senate and ultimately the White House.

The lesson is one that Republicans should take to heart. An election victory is not a blank check from the voters. If Republicans force an unpopular policy on the country, they may well find themselves punished by voters in 2018 and beyond. The defection of conservatives like Billy Long may be a bellwether of a rising public anger that could endanger the Republican majority.

Originally published by The Resurgent

More states consider Medicaid expansion after health bill fail

The failure of the American Health Care Act may have an unintended consequence that will make it harder to dislodge Obamacare’s entitlements in the future. After Speaker Paul Ryan’s admission that “We’re going to be living with Obamacare for the foreseeable future,” several red states are considering Medicaid expansions under the Affordable Care Act.

The Wall Street Journal reports that 19 states, most of which are reliably Republican, rejected the ACA’s Medicaid expansion to cover low-income families after the Supreme Court struck down the mandatory expansion of Medicaid and made it optional for the states. Federal funding for the expanded program was covered at 100 percent for three years and would reduce to 90 percent in 2020. The federal government typically pays about 60 percent of Medicaid spending.

“The thing that held states back was that they were going to end Medicaid expansion,” Adam Searing, a research professor at Georgetown University’s Center for Children and Families, told the Journal. “Now when you have the House speaker saying this is going to stay, it’s like, ‘We may get the money, why not explore it?”

The Kansas Senate voted to approve the Medicaid expansion on Tuesday, two working days after the Republican health bill failed. CNN reports that the Kansas House had passed the bill earlier this year. The bill now goes to Gov. Sam Brownback (R) who is not expected to sign it into law.

“To expand Obamacare, when the program is in a death spiral, is not responsible policy,” Gov. Brownback said.

The Journal reports that several other states are expected to reconsider the Medicaid expansion since the ACA now appears to have survived the Republican challenge. These include Idaho, Florida, Georgia, Missouri, Utah and Wyoming.

North Carolina’s Democrat governor, Roy Cooper, initiated the Medicaid expansion process after taking office in January. The Winston-Salem Journal said that the expansion was a top priority for Gov. Cooper, but he has met resistance from Republicans in the General Assembly.

Ironically, a Republican administration may make it more likely that red states buy into the Medicaid expansion. Secretary of Health and Human Services Tom Price has the power to issue regulations that affect how Medicaid money is spent. A more conservative approach that includes work requirements and more leeway on how states spend Medicaid money may entice Republican state governments to opt in.

If more states enact the expanded Medicaid entitlement, it will be even harder to kill Obamacare in the future. The AHCA was derailed by Freedom Caucus members who, among other things, objected to the way the bill handled the expansion. The AHCA’s slow phase out of the Medicaid expansion was made necessary by four Republican Senators (Lisa Murkowski of Alaska, Corey Gardner of Colorado, Rob Portman of Ohio and Shelly Moore Capito of West Virginia) whose states elected to buy into Obamacare’s Medicaid expansion. If more states expand Medicaid, it is likely that more Republican congressmen will decide to protect the federal Medicaid money flowing to their states.

Some popular Republican governors are already resisting the repeal of the Medicaid expansion as well. John Kasich (R-Ohio), who finished third in the 2016 Republican primary, called the Republican plan to repeal the expansion “a very, very bad idea” according to CNN.

The Trump Administration denies that the effort to repeal Obamacare is over, but there seem to be no plans to move forward. “Have we had some discussions and listened to ideas? Yes,” Press Secretary Sean Spicer told the Journal. “Are we actively planning an immediate strategy? Not at this time.”

As more states and taxpayers receive federal Obamacare money, the law will be harder and harder to repeal. Government money has the power to make addicts of both individuals and states. 

Originally published on The Resurgent

Trump pivots towards Democrats after health bill disaster

The White House issued a warning to Republicans yesterday. In the wake of the failure of the president’s health care reform bill, the Trump Administration signaled that it is willing to reach out to Democrats to advance its agenda if it can’t win support from the various Republican factions.

White House Chief of Staff Reince Priebus underscored the potential shift in strategy on “Fox News Sunday” (quoted in the Wall Street Journal). “This president is not going to be a partisan president,” Priebus said. “I think it's time for our folks to come together, and I also think it's time to potentially get a few moderate Democrats on board as well.”

When asked if President Trump would move on from health care reform and allow the implosion of Obamacare to run its course as he threatened in a tweet, Politico notes that Priebus answered, “I don't think the president is closing the door on anything.”

“It's more or less a warning shot that we are willing to talk to anyone. We always have been,” he said in Time. “I think more so now than ever, it's time for both parties to come together and get to real reforms in this country.”

Since the decision to remove the AHCA bill from consideration on Friday, President Trump has alternately blamed the Democrats, blamed the House Freedom Caucus and reached out to Democrats.

The Washington Times reports that Senate Minority Leader Chuck Schumer (D-N.Y.) was receptive to Trump’s overtures. “We Democrats, provided our Republican colleagues drop [repeal and replace] and stop undermining the ACA, are willing to work with our Republican friends — as long as they say no more repeal,” Mr. Schumer said. Schumer added in Time that, “if he changes, he could have a different presidency.”

With Republicans holding 52 seats in the Senate, virtually all reform legislation is subject to Democrat filibusters. A minimum of eight Democrats must cross over to kill the filibuster and allow a vote on any individual bill.

The Resurgent speculated in January that President Trump might forge a bipartisan coalition of moderate Democrats and Republicans on a number of issues where the president’s platform is at odds with traditional Republican principles. During the campaign, Mr. Trump said that he wouldn’t mind being a “free agent” in his dealings with Congress.

The price for dealing with the Democrats on health care would be giving up the full repeal of Obamacare. Republicans currently don’t have enough votes for repeal, but many, including those in the House Freedom Caucus, would refuse to vote for anything less. The price of bringing Democrats on board other items in the Republican agenda, from tax reform to immigration, is likely to be just as unpalatable. The more the president moves to the left to appeal to Democrats, the more Republicans he will lose. The question is whether he can find a workable majority in the middle.

Originally published on The Resurgent

Where does Obamacare repeal go from here?

The American Health Care Act is dead… at least for now. Next week House conservatives may wake up to the fact that they sided with Democrats to kill a bill that repealed a large part of the Affordable Care Act and defunded Planned Parenthood.  Perhaps the most disturbing thing about the failure of the AHCA is that no better or more realistic alternative for repealing and replacing Obamacare has been offered by the party’s dissidents.

The fundamental problem faced by the GOP is a mathematical one. The Affordable Care Act was passed with 60 Democrat votes in the Senate to overcome a Republican filibuster. It was then amended by a reconciliation bill that only required a simple majority. In 2010, Democrats had 60 seats in the Senate. Today, the Republicans have 52 and five of those are not reliable for a clean repeal. The numbers are just not there for a clean repeal so where does the Republican repeal and replace effort go from here?

Perhaps nowhere. If President Trump stands by his ultimatum that if the AHCA failed that he would bypass Obamacare and move on to other issues, the repeal effort may be dead in the water for the foreseeable future.

On the other hand, while President Trump may not be committed to a repeal of Obamacare, many other Republicans are. However, without the bully pulpit of the presidency backing them, repeal is even more difficult than before.

Republicans face two giant hurdles in their quest to repeal and replace Obamacare. The first is finding a consensus between moderate and conservative Republicans on health policy. The differences range from what to do about the Medicaid expansion to how to treat tax credits for health insurance premiums to defunding Planned Parenthood (Susan Collins, I’m glaring in your direction.) The second problem is finding 60 votes to defeat the Democrat filibuster that is certain to come with any repeal or reform legislation other than a budget reconciliation.

The death of the AHCA does nothing to bridge the gap between the Freedom Caucus and Republican moderates. Like the AHCA, any future bill will have to try to appeal to both wings of the party and, as a result, will probably be reviled by both sides.

Given that the Republicans have only 52 votes available, there are only three viable strategies for repealing the Affordable Care Act.

The Nuclear Option. Republicans can change Senate rules to eliminate the filibuster. The problem is that they still fall short of 51 votes due to probable defections by Susan Collins and the Medicaid Four. Without 51 votes, eliminating the filibuster is pointless and counterproductive. There is a good chance that Republicans will decide to eliminate the filibuster to ram other bills through, but this strategy seems unlikely to help them on Obamacare.

Stall and wait for 60 Senate votes. The Democrats forced the ACA through with a supermajority of 60 votes. Likewise, the GOP could force a repeal if they had 60 votes. The last time that Republicans held a 60-seat majority was the 61^st Congress from 1909 through 1911.

Nevertheless, this is not as unlikely as it sounds. There is a chance for a big GOP win in the Senate in 2018 because 10 Democrat seats in red states are vulnerable to Republican challengers.

The downside is that the 2018 elections are almost two years away and a lot can happen. President Trump is not popular and Republican voters are seething at the way the health care bill was handled. Republicans have blown easy Senate races many times before. A big Republican win in 2018 is probably made less likely if the health insurance system implodes on President Trump’s watch.

Compromise. In today’s political environment, compromise is often seen as a dirty word. Nevertheless, it will be necessary to pass repeal and replace legislation any time soon. Not only will Republicans have to compromise among themselves, something the Freedom Caucus has been largely unwilling to do thus far, they will also have to compromise with Democrats. This is likely to be as unappealing as it sounds.

Democrats hold the key to reforming the health care system. Even if large parts of Obamacare can be repealed through reconciliation, much of the health care reform on the Republican agenda will have to pass a Democrat filibuster. With a minimum of eight Democrat votes needed, Republicans will have to learn give-and-take or resign themselves to at least two years of gridlock.

The failure to repeal Obamacare is not about a lack of will among most Republicans. It is about a lack of Republican votes in Congress, even though they hold a slim majority. If Republicans really want to rid the country of Obamacare, they must go beyond “just say ‘no’” to find a realistic legislative pathway to repeal. This will most likely involve compromising on an imperfect bill that can garner a majority.

Originally published on The Resurgent

How Obamacare Was Passed - And Why It Can't Be Repealed By Reconciliation

A common question since President Trump took office is why Republicans can’t simply repeal the entire Affordable Care Act with a budget reconciliation. The Democrats passed it that way, the argument goes, so why should Republicans have to worry about filibusters, cloture votes and the arcane rules of the Senate when they try to repeal Obamacare?

The most obvious reason is that with the four Republican Senators who are holding out to preserve the Medicaid expansion, Republicans don’t even have a simple majority that would vote for a clean repeal. The Medicaid Four, Lisa Murkowski of Alaska, Cory Gardner of Colorado, Rob Portman of Ohio and Shelly Moore Capito of West Virginia, vowed to oppose any repeal and replace bill that did not allow a phase out of Obamacare’s Medicaid expansion.

A more technical reason is that Obamacare was not passed with a budget reconciliation. Not exactly anyway.

At the beginning of the 111^th Congress in 2009, Democrats held 58 seats in the Senate. The wave election of 2008 had given them a majority that was just short of filibuster proof. Then the Democrats got two lucky – or at least underhanded – breaks. First, in what is often considered to be a stolen election, Al Franken unseated Republican Norm Coleman in a hotly contested recount. Second, Arlen Specter (R-Pa.) switched his party affiliation to Democrat in April 2009. Suddenly, the Democrats had the 60 votes necessary to stop a Republican filibuster in its tracks.

Specter’s defection set the stage for the Senate to pass the Affordable Care Act. On December 23, 2009, the Senate voted to end debate on the bill. The next day, Christmas Eve, the Senate passed the bill in a strict party line vote with every Republican voting “no.” The bill then went to the House of Representatives.

The next month, the Democrats faced a setback when Senator Edward Kennedy (D-Mass.) died suddenly. In a special election widely interpreted to be a referendum on the health care bill, Scott Brown defeated the heavily favored Democrat candidate and broke the Democrats’ filibuster-proof majority.

What saved the Democrats was the fact that the House and Senate had negotiated most of their differences prior to the introduction of the bill into the Senate. To win over the final few House Democrats, the Democrat leadership urged them to pass the Senate bill with no changes and then pass a second bill via the reconciliation process. If the Senate bill was passed without changes, it would avoid going to conference and being subjected to a second Republican filibuster attempt before a final vote. The reconciliation bill, although its content would be restricted to tax, spending and debt limit legislation by Senate rules, would also not be subject to a filibuster.

After President Obama signed an Executive Order that purported to ensure that federal funds would not be used for abortion, Rep. Bart Stupak (D-Mich.) and the last few Democrat holdouts signed onto the bill. The promise not to fund abortion was broken almost immediately.

The Affordable Care Act was passed by the House without amendment on March 21, 2010 and went directly to the president’s desk. The Health Care and Education Reconciliation Act of 2010 was passed by both Houses of Congress on March 25, 2010. President Obama signed the Affordable Care Act into law on March 23 and the Health Care Reconciliation Act on March 30.

The bottom line is that Obamacare passed with two bills. One was a reconciliation bill and one was not. The largest part of Obamacare legislation was passed in a normal bill that Republicans did not have the numbers to filibuster. The Republicans cannot pass a clean repeal because they do not have the votes to stop the Democrat filibuster that would be certain to come.

But what about the 2015 repeal bill that was vetoed by President Obama? How could this bill repeal the entirety of Obamacare and get past the Democrat filibuster to the president’s desk if it was limited to the Senate rules on budget reconciliations?

The answer is that the bill, HR 3762, which was assigned the unwieldy name “To provide for reconciliation pursuant to section 2002 of the concurrent resolution on the budget for fiscal year 2016,” was not a clean repeal of Obamacare any more than the AHCA was. The 2015 bill, like the AHCA, begins with the statement that the Affordable Care Act is amended, not repealed.

A House Republican fact page about HR 3762 also doesn’t make the claim that the bill would have repealed Obamacare in full. The bill summary on the page says, “HR 3762 repeals the health exchange subsidies and the Medicaid expansion included in the Affordable Care Act (ACA), repeals the ‘Obamacare slush fund,’ eliminates federal funding for Planned Parenthood, repeals the individual and employer mandate penalties, and repeals the medical device and ‘Cadillac’ tax, among other provisions.” If you doubt this, you can read the text of the bill for yourself here.

HR 3762 might have been a better bill than the AHCA, but the Republican position in Congress was also better in 2015. Republicans held 54 Senate seats and 246 House seats in the 115^th Congress. In the squeaker election of 2016, President Trump’s short coattails reduced those numbers to 52 Senate seats and 241 House seats. There is still a GOP majority in both houses, but a slimmer one with less margin for defections on votes.

HR 3762 passed the Senate by a 52-47 vote. Two Republicans voted against the measure, Mark Kirk of Illinois and Susan Collins of Maine. Mark Kirk lost his reelection bid in 2016, but Susan Collins remains in the Senate as a prospective “no” vote on the AHCA.

The Medicaid Four were all in the Senate in 2015 and all voted for HR 3762. These four Senators switched their positions on the Medicaid expansion and made it necessary to present a weaker bill to Congress. It is ultimately these four Senators, along with Susan Collins, who should be held responsible for the failure of the GOP to repeal Obamacare because, without their votes, not even a reconciliation bill can pass, let alone a cloture vote on a clean repeal bill.

The failure of the Republicans to pass a clean repeal bill is not due to a lack of will on most members of the party. It is due to math. Democrats used the extremely rare and temporary 60 vote majority to force Obamacare through Congress with no Republican support. The current Republican position is much weaker than that of the Democrats in 2010.

If it is the fault of “RINOs” in Congress, it must be noted that Speaker Paul Ryan (R-Wisc.) is not the RINO to blame. Ryan and other Republican leaders worked to provide the strongest bill possible given the electoral realities of their caucus.

The blame lies with a handful of Republican Senators who are holding up the drive for a strong bill to replace Obamacare. Their names are Lisa Murkowski (Alaska), Cory Gardner (Col.), Rob Portman (Ohio), Shelly Moore Capito (W. V.) and Susan Collins (Maine).

Originally published on The Resurgent

Which is worse: Failure or passage of the GOP health bill?

As the American Health Care Act heads toward an uncertain future in the House, there is speculation that Republicans might be better off if the bill is killed quickly in its first vote. With many members of the Freedom Caucus lining up against the bill, Margot Sanger-Katz and Nate Cohn, who respectively cover healthcare and elections for the New York Times opined on which was worse for the GOP, having the bill fail or having it pass.

 “I think there are two big forces behind the progress of this bill,” Cohn said. “One is that no one wants to be responsible for its failure. So I agree that if the House passes something, there will be a lot more pressure for the Senate to figure something out. They might not be able to do it, but they might really try.”

“Two is that the speed is good for the Republicans,” he continued. “It has a better chance of passing if they move quickly, before public opinion turns against it. It’s better for the Republicans if it fails quickly, because they can move on to other things.”

“I think the Republicans are in a tough spot either way, but I think they’re better off if the bill fails,” Cohn continued. “They’ll get bad press, but voters have fairly short memories and I think the Republicans will move on. They’ll still be able to blame problems on Obamacare, even if it will be less credible. If they pass this plan, I have no idea how they intend to defend it. And I think hurting vulnerable Americans would go against the core of Trump’s appeal to the decisive Obama-Trump vote in the Midwest and Northeast, with little benefit. I think the best position for a lot of Republican members is to vote for the bill, but hope it fails. On the other hand, if the bill passes, it will be nice to be among the Republicans who voted against it.”

If the bill does manage to pass the House, it won’t pass the Senate as written. “The Senate has more of a moderate problem than the House, it appears,” said Sanger-Katz. “There are two senators — Lisa Murkowski and Susan Collins — who don’t like that the bill defunds Planned Parenthood. There are a few senators from states that expanded Medicaid who are worried about changes to that program. There are also some concerns about the generosity of tax credits, particularly for older Americans.”

If the bill is amended to win the votes of Murkowski (R-Alaska) and Collins (R-Maine), it will face increasing opposition from Senators on the right such as Rand Paul (R-Ky.) and Ted Cruz (R-Texas). Still, the best chance for repeal and replace seems to be to pass versions of the bill in both houses and work to improve it in the conference committee that irons out the differences.

The biggest problem for Republicans is the lack of a clear direction if the AHCA fails. “My sense is that there’s just no policy consensus about health care among Republicans,” Sanger-Katz said. “I think they would need that kind of vision and consensus to get something ready in advance.”

Finding a consensus is easier said than done. Many of the problems with the current bill result from trying to find a consensus where there is none. Conservatives want a complete repeal of the Affordable Care Act which is not mathematically possible in the current Congress without Democrat defections. Moderates want to protect citizens of their states that rely on the Obamacare’s Medicaid expansion. The resulting standoff makes it unlikely that enough Republicans can be satisfied to pass any bill without compromise from both sides.

The current bill is the result of an “effort to write this bill, in a hurry, with a jumble of provisions, [that] seems to suggest that they are just trying to find something that can pass, as opposed to articulating a clear policy vision for what they want health care to look like in this country,” Sanger-Katz said.

If the current compromise bill, written to get something passed, cannot pass, what is the future of the Republican repeal and replace effort? Amending it to satisfy members of the Freedom Caucus would probably spur moderates to vote “no” and vice versa. If the bill dies, there is no clear path forward.

Failure of the current bill might have the effect of moving healthcare reform to the left. If conservatives cannot be brought on board, President Trump may tack to the left and craft a bill that could pass with a coalition of moderates from both parties.

Failing to repeal Obamacare won’t be good for Republicans. Neither is passing a bill that leaves much of Obamacare intact. Finding a bill that can pass will require walking a tightrope that leaves the GOP vulnerable to attacks from both the left and the right.

 Originally published on The Resurgent

Republican Health Plan Is Worth a Closer Look

There has been a firestorm of conservative opposition to TrumpCare, as the American Health Care Act is already becoming known. The Republican health care plan has been widely panned and even viewed as a betrayal by many on the right.

To find out more about what the bill contains, I sat down and read it. Unlike Obamacare, the Republican health care bill is posted on the internet in its entirety. The bill took less than two hours to read. You can read it for yourself by going here. References to sections of other laws such as the ACA make it difficult to get the full grasp of some parts of the bill, but it's easy to get a general overview of most of the proposals.

The first two sections deal with “Patient Access to Public Health Programs” and “Medicaid Program Enhancement.” These sections dealt with reforms to Medicaid. Some of the items included, listed in order with their section number were:

·         Banning Medicaid money for abortion providers such as Planned Parenthood (103)

·         Repealing the Medicaid expansion effective January 1, 2020 (112) – The Medicaid expansion was the largest expansion of coverage under Obamacare.

·         Limits the eligibility for Medicaid (114)

·         Creates incentives for states to qualify Medicare recipients more often and penalizes those that carry ineligible people on the rolls (116)

The next section, “Per Capita Allotment for Medical Assistance,” also deals with Medicaid reform.

·         Caps Medicaid spending on a per person basis (1903A)

Subpart D is entitled “Patient Relief and Health Market Stability.”

·         Repeals Obamacare’s cost-sharing subsidy with insurance companies (131)

·         Creates a Patient and State Stability Fund that empowers states to create risk pools for high risk individuals, promote preventive care, reduce costs and reduce out-of-pocket costs for insureds (2202)

·         This section also describes the Continuous Health Coverage Incentive for people who drop their health insurance and sign up again. This is a 30 percent penalty for people who do not have 63 days of continuous coverage in the previous 12 months. This is not a popular provision, but Obamacare’s clause guaranteeing insurability for previous conditions is something most Americans want to keep. If this provision is to be kept, some sort of mechanism is necessary to prevent people from waiting until they get sick to buy insurance. (133, 2711)

·         Amends Obamacare to increase insurance policy options (134)

There are many individual sections of the bill that repeal Obamacare taxes as well. One section of the bill is titled “Repeal and Replace of Health-Related Tax Policy.”

·         Repeals the tanning tax

·         Repeals the tax on prescription medications

·         Repeals the Health Insurance Tax

·         Repeals the Net Investment Income Tax

·         Prohibits tax credits for abortion coverage (02-04)

·         Repeals individual mandate (05)

·         Repeals tax on employee insurance premiums and benefits (07)

·         Repeals tax on over-the-counter medications (08)

·         Repeals tax increase on Health Savings Accounts (09)

·         Repeal of limits on Flexible Savings Account contributions (10)

·         Repeal of medical device tax (11)

·         Repeals the increase in the threshold of the medical income tax deduction. The threshold would return to 7.5 percent of adjusted gross income from the current 10 percent. (12)

·         Repeal of the Medicare tax increase (14)

·         Section 15 deals with the refundable tax credits for insurance premiums. Section 7529 allows advance payment of the credit. This is a problematic section.

·         Increases the HSA contribution limit to equal the amount of the policy’s deductible and out-of-pocket limits (16)

·         Permits catch-up contributions to HSAs (17)

·         Treats medical expenses within 60 days of the establishment of an HSA as occurring on the first day the account was opened. This would allow HSA funds to be used for a condition that occurred shortly before opening the account. (18)

The AHCA is not a perfect bill. It is also not a betrayal of the Republican promise to repeal and replace Obamacare. In fact, many of the provisions in the bill have been on the wish list for conservatives long before Obamacare became law.

Republicans are in a weaker position than Democrats were when they passed Obamacare. As Jamie Dupree of the Atlanta Journal points out, Democrats had 60 votes, enough to break a Republican filibuster, when they originally passed the bill on Christmas Eve 2009. They subsequently lost a vote when Scott Brown (R-Mass.) was elected to the Senate and used the reconciliation process for the second bill of the Obamacare package. Both bills ultimately became law in March 2010.

Republicans have only 52 Senate votes, which is not enough to end a Democrat filibuster. At least four of the Republican votes would not be reliable for a clean repeal bill. A perfect bill is simply not possible.

The current Republican plan is three-pronged. First, the reconciliation process will repeal as much of Obamacare as possible with the AHCA. Second, President’s Trump’s appointees will kill as much Obamacare regulation as possible through administrative rulemaking. Finally, the remainder of Obamacare will be repealed and replaced through a traditional bill. This bill would ideally enact other reforms that cannot be part of the budget reconciliation such as allowing health insurance to be sold across state lines. The third phase will be the most difficult since that bill would be subject to a Democrat filibuster.

Since an outright repeal is impossible and since the AHCA does contain many good conservative reforms, the best solution is to improve the current bill. The American Enterprise Institute has identified several changes that could be incorporated into the AHCA to lower costs and help stabilize the insurance market. Other conservative think tanks and members of Congress could probably improve the bill even more.

Now that the Republican plan is in the open, party leaders should slow down and allow time for a national debate on the merits of the legislation. By rushing forward with an unpopular and flawed bill, Republicans may well repeat the experience of the Democrats who pushed through a bill that only became less popular as its cobbled together provisions made the problem worse. The Democrats ultimately lost control of both houses of Congress and the presidency because of Obamacare. Republicans should learn from these Democrat mistakes.

Conversely, killing the Republican health care reform would be a major victory for the Democrats and may well scuttle efforts to repeal Obamacare permanently. A better solution is to work to improve the current House bill.

Republicans could just say no when Barack Obama was president, but with a Republican in the White House, they have to be realistic. They have to have a plan… a realistic one that can pass the House and Senate. Right now, improving the AHCA seems to be the best option.

 Originally published in The Resurgent

Why Republicans Can't Just Repeal Obamacare

It seems that few, if any, Americans – let alone Republicans – are happy about the GOP health care plan. The plan is being panned by radio callers, medical trade groups and the Freedom Caucus, which plans to offer its own bill with a simple and straightforward Obamacare repeal. Republicans promised to repeal and replace Obamacare, so why not just repeal it immediately? The answer is simple: They can’t.

In the last Congress, the Republicans had a 54-46 majority in the Senate. This fell short of the 60 votes needed to end debate on legislation and the 67 votes needed to override President Obama’s veto. Republicans were effectively blocked by Democratic filibusters even though they had a majority.

In the 2016 elections, Republicans managed to keep control of the Senate, but lost two seats to the Democrats. Republicans now also hold a 59 seat majority in the House of Representatives. With a Republican president who won’t veto a repeal of Obamacare, everything should be easy, right?

Not exactly. Republicans are eight votes short of the 60 needed to bring a bill to a vote. Without at least eight Democrats breaking ranks to vote for cloture, the Senate cannot consider Republican bills. Filibusters and cloture votes are a long tradition in the Senate that have been utilized by both parties. Right now the ball is in the Democrat court.

An exception to the cloture rule is the annual budget reconciliation. The budget reconciliation was created by the Congressional Budget Act of 1974. It requires only a simple majority vote to pass and is not subject to filibusters. The Democrats passed Obamacare into law as part of a budget reconciliation in 2010 and Republicans intend to use the maneuver to pass their own health plan.

So why not use the budget reconciliation to simply repeal Obamacare? Four Republican senators have pledged to join the Democrats in voting against any repeal bill that does not allow a period to phase out Obamacare’s Medicaid expansion. The four, Lisa Murkowski of Alaska, Cory Gardner of Colorado, Rob Portman of Ohio and Shelly Moore Capito of West Virginia, are all from states that chose to adopt the Medicaid expansion. If the four cling to their pledge, a budget reconciliation with a simple repeal would be defeated in the Senate. Given the opposition of the Medicaid Four, Republicans had no choice, but start tinkering with a replacement that would garner their votes.

Republicans are also losing the battle of public opinion on repeal. While repeal – like The Wall – is popular among Republicans, that isn’t the case with the public at large. A spate of recent polls show that Obamacare is actually gaining in popularity. Several polls show that a majority want Republicans to keep Obamacare and change the law to fix it.

So that was what Republicans did. Their American Health Care Plan amends the Affordable Care Act, keeping some of Obamacare’s more popular provisions and replacing other parts with a Republican prescription for change. The result was a bill that seems to have pleased no one except President Trump.

Now the Republican TrumpCare bill seems as unlikely to pass as a straight repeal would have been. Members of the Freedom Caucus are coming out against the bill in the House. In the Senate, Rand Paul (R-Ky.), Mike Lee (R-Utah) and Tom Cotton (R-Ark.) have lined up against the bill and Ted Cruz (R-Texas) seems likely to join them in voting no.

That Republicans could have written a better health care bill is not a question. Speaker Ryan presented his own health care plan based on conservative principles last summer. Several other plans have been floated as well, including one by Tom Price, the new Secretary of Health and Human Services. Any one of them would have been more popular than the current bill.

Nevertheless, it isn’t the whole GOP that is preventing the repeal of Obamacare. It is the Medicaid Four.

At this point, repeal of Obamacare seems as unlikely as it did when Barack Obama was president. As under Obama, the reason is simple. Even with a congressional majority and a friendly president, Republicans don’t have the votes to kill Obamacare. The best idea for the GOP right now would be to scrap the current bill and go back to the drawing boards for a bill that will win the support of the Medicaid Four as well as the Freedom Caucus.

Originally published on The Resurgent