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If you listened to President Trump last December, you might think that Obamacare was repealed. In reality, Republicans repealed the law’s individual mandate, but left most of the ACA intact.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

Bill Cassidy Fires Back at Jimmy Kimmel

Senator Bill Cassidy (R-La.) has responded to Jimmy Kimmel’s charge that Cassidy “lied right to my face” about health care reform. On MCNBC’s “Morning Joe” and a separate CNN interview, Cassidy claimed that the Graham-Cassidy bill does meet the “Jimmy Kimmel test.”

“I'm sorry he does not understand," Cassidy said. “More people will have coverage and we protect those with pre-existing conditions.”

The Graham-Cassidy bill allows states to apply for waivers from Obamacare’s essential health benefits requirement. The bill would require that states exercising waivers to show that coverage would still be “adequate and affordable” for those with pre-existing conditions. Kimmel and other critics argue that this requirement is too weak and vague to offer protection.

“The counterargument will be pre-existing conditions will be up to the pricing of the particular state and market,” countered CNN’s Chris Cuomo. “So, the protection is not the same, senator, on that one point.”

“The protection is absolutely the same,” Cassidy answered. “There is a specific provision that says that if a state applies for a waiver, it must ensure that those with pre-existing conditions have affordable and adequate coverage.”

Cuomo argued that people with pre-existing conditions would pay more, based on a schedule of rates being circulated.

“I think the price will actually be lower,” Cassidy responded. “What is being circulated is by those that wish to preserve Obamacare and they’re doing everything they can to discredit the alternative.”

The Congressional Budget Office is currently scoring the bill, but because the budget resolution must be passed before the end of September, the analysis will be incomplete. “CBO will not be able to provide point estimates of the effects on the deficit, health insurance coverage, or premiums for at least several weeks,” the office said in a statement.

“There will be more people covered under this bill than under the status quo,” Cassidy claimed.

Originally published on The Resurgent

Jimmy Kimmel Goes Off on Bill Cassidy Over Health Bill

Late night host Jimmy Kimmel veered off into leftist politics again last night when he ripped into Senator Bill Cassidy (R-La.). In a seven-minute monologue on Jimmy Kimmel live, Kimmel charged that Cassidy “lied right to my face” about promises that he made to Kimmel regarding Obamacare reform in an appearance on the show in May.

The controversy centers over Cassidy’s promise that a healthcare reform bill would meet the “Jimmy Kimmel test,” a term that Kimmel says was coined by the senator. “In a nutshell,” Kimmel said, the test holds that “no family should be denied medical care — emergency or otherwise — because they can't afford it.”

“He said he would only support a healthcare bill that made sure a child like mine would get the health coverage he needs," Kimmel continued, "no matter how much money his parents make, and that did not have annual or lifetime caps.”

Cassidy appeared on Kimmel’s show in response to another monologue in which Kimmel described how his infant son required heart surgery that could be considered a pre-existing condition.

Dr. James Madara, president of the American Medical Association, wrote in Fortune that the bill could possibly allow states to opt out of affordable coverage for pre-existing conditions. “While insurers are still required to offer coverage to patients with pre-existing conditions,” Madara wrote, “allowing states to get waivers to vary premiums based on health status would allow insurers to charge unaffordable premiums based on those pre-existing conditions.”

Kimmel said that the Graham-Cassidy bill passed a different Jimmy Kimmel test. “Your child with the pre-existing condition will get the care he needs if – and only if – his father is Jimmy Kimmel. Otherwise, you might be screwed,” he joked.

While the bill does not eliminated coverage for pre-existing conditions or allow insurance companies to establish caps for lifetime benefits, the bill does return the power to regulate insurance to the states. Politico notes, “States would be allowed to apply for waivers that could change what qualifies as an essential health benefit,” a term originally defined by the Affordable Care Act. The waivers could “impact people with pre-existing conditions and undermine prohibitions on annual and lifetime limits for insurance coverage.”

Kimmel thanked Senators Lisa Murkowski (R-Alaska), Susan Collins (R-Maine) and John McCain (R-Ariz.) for voting to kill the previous Republican healthcare bill. He urged the trio to vote against Graham-Cassidy as well.

In a part shot, Kimmel invited Cassidy to work for a health care bill that met with Kimmel’s approval, “and if not, stop using my name, because I don’t want my name on it.”

“There’s a new Jimmy Kimmel test for you,” Kimmel scolded Cassidy. “It’s called a lie detector test. You’re welcome to stop by the studio and take it anytime.”

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

Cruz-Lee Provision Is Reportedly In New Health Bill Draft

As Republicans scramble to find enough Senate votes to keep their health care reform effort alive, there are reports that the most current draft of the bill will contain a provision written by Mike Lee (R-Utah) and Ted Cruz (R-Texas) that is popular with conservatives. Axios cites three sources familiar with the bill who say that the proposal of the two conservatives to allow a liberalization of health policy requirements is part of the bill at least for the time being.

Under the Consumer Freedom Protection option, health insurance companies that sell policies that are compliant with the requirements of the Affordable Care Act will be allowed to sell noncompliant policies as well. The ability to buy noncompliant policies should help consumers find lower cost health insurance.

The ACA mandates “essential health benefits” that must be included in health insurance policies. These requirements often include coverages that consumers may not want, need or can afford. The requirement to provide these coverages in all plans drives up costs and puts insurance out of reach for many consumers.

Critics of the provision say that healthy consumers will choose the lower cost noncompliant plans while those who are sick will likely buy the more expensive compliant plans. They argue that this will contribute to the death cycle of Obamacare and raise the cost of insurance for people with pre-existing conditions. These costs would be passed along to the federal government through insurance subsidies.

Over the past few months, the GOP reform effort has been losing support from both the center and the right. Republican moderates oppose the bill because of its phase out of the Medicaid expansion while conservatives argue that the bill does not go far enough in repealing and replacing Obamacare. Inclusion of the Cruz-Lee provision may have the effect of winning back the votes of some members of the conservative wing of the party.

The Axios report also gives several other details about the current version of the bill. The new version increases the amount of money for states to stabilize their health markets and cover pre-existing condition to more than $170 billion. It also keeps two of the Obamacare tax increases on wealthy families. Other new provisions allow consumers to pay insurance premiums with money from health savings accounts that receives favorable tax treatment and allow people receiving ACA insurance subsidies to buy lower cost insurance policies that provide only catastrophic coverage.

The laws of supply and demand dictate that as prices fall, demand will increase as more people can afford the product. As the price of health insurance decreases, more people will decide that insurance protection is worth the cost.

Republicans had planned to vote on the bill before the Independence Day recess, but delayed the vote due to opposition from Republican senators. Majority Leader Mitch McConnell (R-Ky.) said that he hopes to bring the bill to a vote next week. 

Read the full story 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

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

California Insurers Warn Of Collapse of Health Care Exchanges

Californians may be about to experience the collapse of the Obamacare exchanges in their state. Insurers in the Golden State are threatening to raise premiums and exit the Obamacare insurance exchanges if the Affordable Care Act’s cost sharing payments are not made. The payments, which are made to insurance companies by the federal government, subsidize the losses that insurers accrue from insuring people with pre-existing conditions without charging higher prices.

In April, the Trump Administration said that it planned to continue the payments, which total $7 billion per year, and also threatened to withhold the money in an attempt to pressure Democrats. The payments were absent from the compromise spending bill that the parties agreed on to avert a government shutdown.

In the past, the money for the payments was appropriated by the Obama White House because the Affordable Care Act authorized the payments, but never appropriated them. House Republicans sued President Obama to stop the payments on the grounds that only Congress has the constitutional power to appropriate funds. The House won the lawsuit, but the White House payments were allowed to continue pending appeal.

Now two California insurers say that if the government fails to make the payments, it could be disastrous for California’s health insurance markets. The Washington Free Beacon reports that Covered California, the state Obamacare exchange, says that premiums could rise by as much as 49 percent without the government subsidy to insurance companies. A private company, Molina Healthcare, threatened to exit the exchange entirely without the payments.

“If the CSR [cost-sharing-reduction payments] is not funded, we will have no choice but to send a notice of default informing the government that we are dropping our contracts for their failure to pay premiums and seek to withdraw from the Marketplace immediately,” J. Mario Molina, the CEO of Molina Healthcare wrote. “That would result in about 650,000 to 700,000 people losing insurance coverage in 2017, and we would not participate in Marketplace in 2018 resulting in over 1 million Americans losing health coverage.” The company currently insures more than a million Californians.

The prospect of insurers fleeing the market and premiums rising drastically underscores the urgent need for the passage of a health care reform package. The same market forces that affect health insurance in California operate in the other 49 states as well. If voters around the country see insurance premiums skyrocket while having fewer insurers to choose from, the backlash will most likely be against the party in power. Even though President Obama and the Democrats created Obamacare, President Trump and the Republicans were hired to fix the mess, not preside over the collapse of the health insurance industry.

President Trump and the Republicans are between a rock and a hard place on healthcare. The Republican Congress is unlikely to approve the insurance company subsidies so if President Trump wants to continue the payments he must continue the Obama Administration’s appeal against the House Republican lawsuit. As insurers and voters fret, Republican moderates and conservatives continue to dither over the details of how to reform Obamacare. Meanwhile, the clock is ticking on the ability to use a budget reconciliation to avoid a Democrat filibuster.

Health care and health insurance are issues that affect the lives of virtually every American. As Obamacare collapses and prices rise, it is vitally important that Republicans unite to solve the problem. If the party drops the ball on this cornerstone of every campaign for the past seven years, the consequences might be dire, not only for the Republican Party, but for the country as a whole. 

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

It's time to stage an intervention for Republicans

When I was growing up, a frequent trope on television sit-coms was to stage an intervention for characters whose destructive behavior was getting them into trouble. The episode would involve other members of the cast gathering together to show the character with the problem how they were destroying their life with the hope of convincing them to change their ways. This week, as the prospects for repeal and replacement of Obamacare grow ever dimmer, it is time for an intervention for Republicans.

Obamacare cannot be repealed.

There. I’ve said it.

As a popular meme series might put it, “Stop trying to make full repeal happen. It’s not going to happen.” At least for now, this is the hard truth for conservatives.

The truth is that Republicans don’t have the votes to repeal Obamacare. The Democrats passed the Affordable Care Act with 60 votes, enough to end the Republican filibuster two days before Christmas in 2009. Republicans also need 60 votes to stop a Democrat filibuster of a repeal bill. There are 52 Republicans in the Senate. You do the math.

Repealing Obamacare is not mathematically possible without at least eight Democrats crossing the aisle. Reforming Obamacare is possible through a budget reconciliation. That should be our goal. We should be talking about health care reform instead of repeal.

Ted Cruz (R-Texas) advocates the 2015 repeal bill that was vetoed by President Obama, noting that “Virtually every Republican in Congress voted for that language, and the parliamentarian has already ruled it as permissible.” This bill is also unattainable, however. Cruz fails to note that four Republicans who voted for the 2015 bill now refuse to vote for a bill without a phase out of the Medicaid expansion. The 2015 bill was also not a full repeal.

Otto von Bismarck said that “Politics is the art of the possible, the attainable — the art of the next best.”

That is what Republicans should focus on: What is possible, attainable, and the next best thing to full repeal that can actually pass. That is going to involve the ugly art of compromise. Any bill that can pass is not going to be everything that the conservative and moderate Republicans have on their respective wish lists.

The question for Republicans is this: Is a compromise that reforms Obamacare but falls short of repeal better than leaving the current monstrosity in place in its entirety? The answer should be a resounding “yes!”

Repeal is the ultimate goal, but it is not going to happen within the next two years. The current, short-term goal should be to take baby steps toward fixing the health care mess that Obamacare created. If Republicans can create a policy compromise that makes things better for most Americans, then hopefully voters will trust them with a larger majority in 2018.

Even then, it probably won’t be a slam dunk. Sixty-seat supermajorities don’t come along often. This is especially true for the Republicans who last had 60 seats in 1911. As long as there is a filibuster, compromise and forging bipartisan majorities is going to be necessary to advance conservative legislation.

Conversely, the more dysfunctional the party acts, the less likely voters are to give Republicans more power.

Since the defeat of the AHCA, President Trump has realized that he needs some Democrat votes and has started reaching across the aisle. The question is whether conservative Republicans will be left behind in the new reality or whether they will use their influence to craft the best, most conservative bill that can pass. If conservatives don’t play ball with the “nonpartisan” president, they may well find a new reform law passing that is even less likeable than the AHCA.

There is no honor for Republicans in insisting on a perfect bill that will never become law. There is no honor in killing imperfect bills that can improve the lives of hardworking Americans. The honor for Republicans will be found in coming together and building a bill that both conservatives and moderates can say “yes” to.

Voters did not send Republicans to Washington with a blank checkbook. For better or worse, Republicans were given a slim majority and a president who is not a conservative. No one faction of the party can enforce its will on the others. To accomplish anything, Republicans must learn to work together and get beyond the “just say ‘no’” mentality.

Voters did send Republicans to Congress to fix the Obamacare mess. If the ACA cannot be repealed, then it should be reformed where possible. Republicans should roll up their sleeves and get to work doing just that. 

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