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Paul Ryan’s Triumph

Well, they pulled it off. House Republicans, who occupy 238 of their chamber’s seats, managed to eke out a 217–213 majority for the Obamacare repeal they’ve been promising for years.

In all seriousness, this is a triumph for Paul Ryan & Co. Because the original version of the American Health Care Act failed with conservatives and moderates alike, the leadership had to move the legislation to the left and right simultaneously. It was no small feat to assemble just the right combination of amendments, a mix that allows states to aggressively roll back sacrosanct Obamacare regulations but also requires those states to take steps to help the uninsured.

But now that the confetti has settled, I’ll ask two impertinent questions. Given that the Senate won’t even use the House bill as a starting point [1]—though it will incorporate elements of the AHCA as it sees fit—how good are the chances that the two chambers will eventually see eye to eye? And given that the American public would like to see universal health coverage [2], a goal Trump has claimed to support as well, can the AHCA be any more popular than Obamacare has been?

Let’s start with a quick overview of what the AHCA does. Here’s what remains unchanged since it flopped in March: It eliminates the individual mandate, but those who go without insurance will have to pay a 30 percent surcharge for a year if they decide to sign up later. It eliminates Obamacare taxes that targeted the wealthy. It allows insurers to charge the oldest enrollees five times what they charge the young, instead of three times as under Obamacare. Instead of giving tax credits that vary dramatically with income to ensure everyone can afford coverage, it provides flatter credits that rise with age and gently phase out at high incomes. And it eliminates the Medicaid expansion and puts the entire program on a per-capita budget. (Medicaid is currently an open-ended guarantee [3] by the federal government; if a state spends more, it gets more federal funding.)

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According to the Congressional Budget Office, those provisions would increase the number of uninsured Americans by 24 million in 2026. On the plus side, they would also reduce the deficit $150 billion by the same year.

That score was published before the new amendments giving states waivers from major Obamacare regulations, though, and it’s not entirely clear how those changes will affect the numbers. (We’ll have a new score before the Senate votes on anything.) But since most of the original bill is untouched, it’s likely that there are still enormous coverage losses, at least according to the CBO’s methodology. And as the Committee for a Responsible Federal Budget explains [4], if the amendments do increase coverage somewhat—for example, if states get waivers and use them to offer super-cheap plans to the young and healthy—the tax credits these people use will eat away at the previous version’s deficit savings. In fact, if coverage goes up 6.5 million or more relative to the previous version, all the deficit reduction will be wiped out.

So back to those questions. Even aside from the simple fact of coverage losses, liberals have several lines of attack that could resonate with the public, and with Senate moderates trying to decide how much of the House bill they can include in their own legislation. If more than two GOP senators refuse to back the effort, it dies, because Republicans are starting with just 52 votes.

Take preexisting conditions, the subject of much discussion this week. The amendments dealing with this issue are not as bad as some make them out to be [5], but they do raise serious policy questions. Basically, if they wanted to, states could lift Obamacare’s ban against charging sick people more for insurance—though this would apply only to customers who had not maintained continuous coverage, a situation that would be easier to avoid than it was before Obamacare, thanks to the AHCA’s tax credits. Further, states that went this route would have to take measures to help those at risk of being uninsured. They would have several options, the most hyped of which are called “high-risk pools.”

The problem is that many states had high-risk pools before Obamacare, and they didn’t work very well. As the name implies, the idea is to take all the sickest uninsured people and put them in a separate pool so they don’t drive up premiums for everyone else—but this is an incredibly expensive pool that requires substantial government subsidies. States that operated these pools usually underfunded them, offering plans with unaffordable premiums, poor coverage, and sometimes even waiting lists. Health-care experts across the spectrum say the federal funding in the GOP bill, despite an increase won by the party’s moderates, is probably not enough to solve this problem. The ultimate fear is that some states could end up where they were before Obamacare, when there were perhaps a few million [6] sick Americans who couldn’t get coverage.

Medicaid will also prove fruitful for those trying to sink the bill. All the way back in March, four GOP senators objected [7] to the way the House bill treats the program. Don’t forget that a lot of red states chose to expand Medicaid even after the Supreme Court said they didn’t have to.

The structure of the tax credits also bothers some moderates. While older people can be charged five times as much, their credits are worth only twice as much. And because the AHCA’s credits vary less with income than Obamacare’s do, they do less to help the poor.

Still another line of attack comes from a Thursday morning Wall Street Journal story [8]. According to the report, thanks to some obscure legal quirks, the AHCA could allow employer plans to enforce annual and lifetime coverage limits that were banned under Obamacare. It’s unlikely that many employers would want to do this, and Republicans say it stems from a misreading of the law and in any case could be fixed through executive regulations. But at the very least, the pure politics of a threat to employer plans is not good.

A few other odds and ends regarding the Senate: Some moderate Republicans object to the fact that the bill defunds Planned Parenthood. And in order to pass the bill with 50 votes, instead of stopping a filibuster with 60, the Senate will use the “budget reconciliation” process, which limits what can be included in the bill. If the Senate parliamentarian decides that key elements of the legislation aren’t directly budget-related, Republicans will have to either remove those elements or take the dramatic step of overriding the parliamentarian. Finally, while moderates will probably be the biggest threat, Freedom Caucus-style conservatives in the Senate, such as Ted Cruz, could refuse to back the bill if it drifts too far left.

The consensus [9]—among observers and among senators themselves—is that whatever the Senate ends up with will not look very much like what the House just passed. This could put both houses in a very difficult place. If the House struck a delicate balance to get to a 217–213 vote, and the Senate has to strike a completely different balance to get to, say, 51–49 (or even 50–50 with the vice president breaking the tie), there may be no policy mix acceptable to both unless legislators start caving on issues they care about.

Or as Rep. David Brat (R-Va.) asked the Washington Post [10], “Have you been watching for the last few months how tight this is, and you’re going to shift this one [way] or the other? … Good luck, you don’t have to be Einstein to game theory that one.”

Robert VerBruggen is managing editor of The American Conservative.
Follow @RAVerBruggen [11]

23 Comments (Open | Close)

23 Comments To "Paul Ryan’s Triumph"

#1 Comment By Kurt Gayle On May 5, 2017 @ 10:55 am

Robert, you deserve so much credit for cutting to the heart of this matter. You ask what should be the central question:

“Given that the American public would like to see universal health coverage, a goal Trump has claimed to support as well, can the AHCA be any more popular than Obamacare has been?”

The answer is “No!” The AHCA cannot be any more popular than Obamacare has been, and may well be even less popular.

PEW Research reported in January: “Currently, 60% of Americans say the government should be responsible for ensuring health care coverage for all Americans, compared with 38% who say this should not be the government’s responsibility. The share saying it is the government’s responsibility has increased from 51% last year and now stands at its highest point in nearly a decade.”

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“Now is the hour.” The time is right for President Trump to do what President Obama was unable to do, but what the American people desperately want done:

BRING IN UNIVERSAL HEALTH COVERAGE!

#2 Comment By collin On May 5, 2017 @ 11:51 am

There is a lot that could backfire here:

1) Few conservative sites are celebrating this as a great victory and Breibart is focused on increased to guest programs. So the ‘Trump’ base does not seem to celebrating like the House Rs.
2) The liberal blog sites are lit up like Christmas. Daily Kos and TPM are calculating how many voters in R House locations are losing insurance.
3) Notice the Democrats running for the Special Elections, Gist and Ossof, are screaming against AHCA while the Repbulicans are quiet.
4) Remember Joe Manchin quote “Trump voters will know Republicans took their health coverage away”

Otherwise, Why is Trump NOT taking pictures with Joe Manchin?

#3 Comment By The Other Sands On May 5, 2017 @ 12:57 pm

Congrats on the GOP for once again making crystal clear just how callous they are, on our way towards the US having single-payer universal coverage anyway. It is inevitable, whether it takes 5 years, or 10, or 20. And whatever the right claims when it happened, it will be Obama and his Dem Congress that goosed us into doing it. Trump will have nothing to do with it.

But the GOP can be happy to symbolically smash the poor and sick back down into the mud one last time before that happens. And then celebrate with beer and glad handing at the White House. It is striking the pure glee with which the GOP openly screws the poor in service of rich, and then claim it is the left that fights “class warfare.”

Anyway, all the old white men celebrating in the Rose Garden yesterday apparently need more education how a bill becomes law. The Senate won’t touch this turd. On to the next symbolic nonsense….

#4 Comment By Steve in Ohio On May 5, 2017 @ 1:38 pm

BRING IN UNIVERSAL HEALTH COVERAGE!

This just doesn’t seem possible politically. Democrats hate Trump so much that few would back such a bill even though most badly want it. Very few Republicans would support universal coverage for ideological reasons.

A possible compromise would provide a public option. (John Derbyshire has proposed that anybody wanting to go on Medicaid should be allowed to.) The private sector would be totally unregulated. Such a system would be similar to higher education: most middle class kids go to state schools while the rich go to Ivy League and other private colleges. Not a perfect system, but most kids get a decent education at a reasonable cost.

#5 Comment By bacon On May 5, 2017 @ 1:50 pm

I don’t see how Republicans can win on health care, unless they come up with something that expands coverage for all, which they seem to think is an existential evil. If the AHCA dies after the senate works its magic they will be seen to be inept (who doesn’t already see them as inept?), and if they get something like what the house proposes signed into law millions will lose care, most of them Trump/Republican voters. Of course, Trump et al will say the Democrats are responsible for any bad results and many of his supporters will agree.

I don’t care who gets the blame or the credit. As a physician, I want to see anyone who has a need for health care to be able to get it. Health care in the US is a business and for business profit is the bottom line. Countries that provide better care for less money (there is no shortage of them) have moved health care from a for-profit business to a public service. We don’t do that because those who would have to back such a change, our elected officials, are in the pockets of those who profit.

#6 Comment By John Mulligan On May 5, 2017 @ 2:10 pm

Mr. Trump has set the stage. If his AHCA succeeds he will deliver death to American babies – yes poor, innocent American babies – as surely as he claims that Mr. Assad has delivered death to Syrian babies.

#7 Comment By Cornel Lencar On May 5, 2017 @ 6:10 pm

The whole argument was described by Paul Ryan with a simple pie chart which showed the 20% of sick people versus the rest and asking why the rest has to pay for the sick?

The issues are a bit compounded here:
1. Those 20% sick are not the same all the time and they come from all segments of the population: very young, mature, old; poor or rich.
2. However, the majority are poor or old or both.

The rich have decided that that they don’t accept to be taxed to pay for the healthcare of the poor. And of course this has racial undertones, since blacks will be more likely in the poor segment.

A Harvard guy, that helped set up the Taiwan insurance system for healthcare said the the first question, ethical/moral question, is whether a nation wants to provide healthcare access to everyone. While the majority of the Americans seem to want that, the rich that run the government have decided that the answer is no.

U.S. is a morally bankrupt country, full of rhetoric and nothing else.

#8 Comment By SteveM On May 5, 2017 @ 6:53 pm

Like with Obamacare this Pyrrhic Republican victory will collapse into an economic catastrophe. Because like Obamacare, the Republican plan just moves the “who pays” food around the plate and does NOTHING to actually control the cost of health care, i.e., the out of control costs for services.

U.S. health care is now $10,000 per capita annually and it will still be $10,000 per capita when the Republican mess is fully implemented. BTW Germany is $5,300 per capita.

U.S. health care is comprised of an interlocking set of Crony rackets and cartels, (i.e., Big Insurance, Big AMA, Big Hospital, Big Pharma) that price fix, stymie competition, collude on pricing and erect huge barriers to entry. E.g. why is there nothing in the bill requiring totally transparent pricing before service is provided? There is a massive shortage of doctors, so where is the plan to increase physician throughput by 25%?

Because the Republicans are all in on the con. As I’ve stated several times, the U.S. health care system is systemically busted. It cannot be “reformed”. It can only be blown up and replaced with something else. Stakeholders are going to have to take haircuts, so who will it be and how short?

Steven Weissman, who ran a hospital provides a simple outline of health care pricing pathology:

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It’s not clear to me why people like Robert VerBruggen won’t take the 5 minutes to read Mr. Weissman’s column to update their understanding of how lame the Republican proposal actually is. Even though there are obvious first order solutions staring them in the face.

#9 Comment By Interguru On May 6, 2017 @ 1:09 am

Calling this AHCA proof that Republicans can govern is like an 8th grader who struggles for a month to write a two hundred word essay. Finally she gets two hundred words on paper at the last minute, turns it in with no editing or checking, and declares herself a writer.

#10 Comment By EliteCommInc. On May 6, 2017 @ 1:28 am

If you spent an inordinate amount of time laying claim to your core beliefs and then jettison them for the sake of who knows what, maybe they were never core beliefs in the first place or they were never shored up against the storms. I neither case that level of breaking can hardly make one triumphant.

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” Countries that provide better care for less money (there is no shortage of them) have moved health care from a for-profit business to a public service.’

We have had these discussions on several occasions and when it comes to better for less, those numbers never meet the claims. It’s a common refrain, especially for countries that have half or less than half of our populations.

I have to reject spending money we don’t have for programs that guarantee that the goal of decreasing costs is depressed by government programs.

#11 Comment By Balconesfault On May 6, 2017 @ 6:07 am

Thank you Bacon. Healthcare being a for profit endeavor is the structural root of many of our problems.

OTOH, I often argue that labelling it a “right”, as so many on the left do, creates its own set of unmanageable problems.

How about … Universal Healthcare is just a smart way for a prosperous First World country to do business?

The irony is that even prior to passage of the ACA the US spent more public dollars per capital ​on healthcare than any other nation but Switzerland when you summed up all the pots (Medicare, Medicaid, retired military, VA, various tax subsidies, employee benefits at the Federal, State, and local level … Including teachers/workers at all public schools and colleges).

All that with an equivalent amount of private dollars being spent per capital … without approaching Universal Coverage.

Some places, the free market is structurally incapable of leading to the desired outcome (lower healthcare spending without millions suffering and dying unnecessarily).

#12 Comment By Kurt Gayle On May 6, 2017 @ 8:18 am

“Is Trump right about Australian healthcare? The US president told the Australian prime minister his country had better healthcare.”

BBC News video, May 5, 2017 (1:23)

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#13 Comment By Johann On May 6, 2017 @ 10:04 am

Since there is no way to pass any bill given the Dems will always be an automatic no, there is no other choice other than to let Obamacare crash and burn. Then, simply repeal Obamacare, which can be done with Republicans only. Then, pass a government health care welfare give-away program to the poor, and let those who take care of themselves continue with their own insurance coverage, whether it be through their employers or whatever. So it will be a single govmint payer for the poor, and private for the self sufficient.

PS – would someone please get me out of the auto spam dump? For several months now the only way I can comment is to use the TOR browser which hides my IP address.

#14 Comment By Jimbo On May 6, 2017 @ 10:40 am

Meh, the GOP is playing hot potato – they do not have the votes to pass any health care bill without Democrats. The ideological split is too big between the “Government has no place in the medical field” and “Maybe it does, but this isn’t it” groups. Paul Ryan was desperate to pass something to to prove he can make big votes and hasn’t been a total joke of a Speaker; so now he’s proudly thrusting a turd sandwich into the Senate (he’s been worse than Boehner, who had a wing of his caucus rebel against him AND was breathtakingly cowardly in confronting them). McConnell won’t touch the House bill and will draft up a new one that may or may not pass the House. The GOP, desperate for a win, will have to weigh the reality of passing an awful piece of legislation or failing to pass any legislation.

When all is said and done, it’s really a testament to the GOP’s leadership that the first thing they want to do is have an earth shattering, irreconcilable, multi year argument about something they have never had a policy about. In their hour of greatest electoral triumph, they have celebrated it by crucifying themselves in slow motion.

#15 Comment By Nate of the North On May 6, 2017 @ 4:30 pm

I have often struggled to determine in what way any material on this website is conservative. (With the exception of Patrick Buchanan)
I’ve come to realize that what it seeks to conserve is
the statist liberal consensus.
The liberals have become the establishment, and it turns out their utopia is just as flawed as the last one.

#16 Comment By Anonymousdr On May 6, 2017 @ 8:35 pm

@bacon

I’m a physician too and share your goals, but look, only 20% of us hospitals are “for profit” and its not as if the Swedish or French governments are in the business of making medical devices or drugs.

Pretty much every health system in the industrialized world is, when looked at in its totality, a hybrid public private system- relying on differing levels of public funding and regulation-to be sure.

We have the worst of all worlds. Too bad no one on the right is looking at good heavily private systems like Switzerland and the left keeps harping on single payer, when most of the really good systems (French, Swiss, German) are hybrids. The NHS is kind of crappy and Canada is exceptional.

#17 Comment By Kurt Gayle On May 7, 2017 @ 11:33 am

How the Republican health care bill can bring “movement toward a government-run public option, or single payer”:

Peter Suderman, features editor at Reason magazine, and a long-time critic of Obamacare writes in today’s New York Times:

“The Republican [health care] alternative is worse in nearly every way… It is not too hard to imagine, for example, that if the Republican bill becomes law in something like its current form, and the exchanges melt down, disrupting coverage for millions in the process, that the result will be calls for further government intervention — for bailouts and, if the system collapses into complete chaos, movement toward a government-run public option, or single payer.

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#18 Comment By EliteCommInc. On May 7, 2017 @ 3:03 pm

“When all is said and done, it’s really a testament to the GOP’s leadership that the first thing they want to do is have an earth shattering, irreconcilable, multi year argument about something they have never had a policy about. In their hour of greatest . . .”

I have felt for a long time that my view on the matter of healthcare will eventually be a pea. Reading the commentary on this issue, is in my mind that perhaps healthcare as a national program is on its way.

What disappoints is that Speaker Ryan didn’t have it in him, to remove every provision permitting killing children in the womb.

“I have often struggled to determine in what way any material on this website is conservative.”

This is accurate. But this is also accurate about periodicals such as: National Review, Red State, the Spectator, Weekly Standard even the Wall Street Journal and others.

The liberalism creeps in via the issues they adopt based not on principle, but power associations. Th tentacles of various foundations and the inter/intra-relations they form.

Neocons / interventionists

globaliztion / immigration advocates

women’s issues — the most insidious and pervasive deconstruction of conservative thought

Social and Psychological theorists

Liberalism is where the world is headed. And standing against it will require finesse and an iron will. For there’s no escaping its consistent spread. I guess its easier when you single.

#19 Comment By Brendan Sexton On May 7, 2017 @ 4:22 pm

The elephant in the room here–the key motivation for Ocare repeal that no one seems to mention—is that the driver for Republican opposition to Ocare is the desire to get rid of the tax increases on the wealthy that funded the more popular features of the bill, like coverage for the really sick, expanded Medicaid, etc.
This is why the original program was just to ‘repeal’–it took months and months of really hostile public reaction to that idea to move the Rs to ‘repeal and replace.’ What they were (are) really after is a tax cut for the wealthy; they are being forced into doing it with somewhat less disastrous results than we’d have with straight repeal.
They did NOT start with–most of them have never even gotten to–‘how do we get people healthier?” or even “how to we get affordable insurance to folks who need it?” I don’t mean they don’t care at all about these goals–although a disappointing fraction of the R voices in this debate in fact don’t seem to–it’s mostly just that these public benefit concerns are not at the heart of the Republican approach, are not fundamental, do or die principles they will sacrifice much (like taxes on their wealthy sponsors) to obtain.
So in the complicated negotiations over the complicated mess we call health care funding/insurance, these non-core concepts are whittled away, or deformed past the point where we (the public) can even be sure we know what the hell they are going to do the benefits we charish the most.
The one thing that does not get mashed around, distorted, traded away, is that the Ocare taxes on the rich must be banished. It’s just not that hard to see. (for she who has eyes to see).
Health care costs a LOT and if we intend to make it more widely available, it will cost plenty. Ocare grappled with this problem by injecting tax dollars. They R approach(es) seems to take the other end of the stick–simply chop off pieces of the care covered–fewer services, for fewer people, less regulatory requirement for prevention, etc.
It’s ALL just to enable tax relief for the wealthy. That is the first goal, and the only one to survive the massive, complicated negotiations.That’s what they care about, and that doesn’t strongly imply better health outcomes for anyone or better financial outcomes for anyone except those same wealthy. Why does this seem so hard to understand?

#20 Comment By Mike Schilling On May 8, 2017 @ 3:10 am

Ryan got a GOP House to pass a huge tax cut for the wealthy. He’s a genius!

#21 Comment By Jerry Todd On May 8, 2017 @ 10:50 am

Maybe the Senate can use this for a guideline…
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#22 Comment By EliteCommInc. On May 8, 2017 @ 3:13 pm

” Why does this seem so hard to understand?”

I think you allude to it quite well. Framing republicans and conservatives as uncaring is an effective weapon. If all one has to do is point to people such as myself and call us bad people, then one avoids dealing with reasons we are not onboard any government delivery system.

And the fact that we still have mandated insurance and medicare and medicade and SSC healthcare as well as additional government oriented programs says why government is a problem.

The Heritage foundation model and its offspring in Mass. have not answered the issues of why people contend something is needed.

In response to Australia’s healthcare system, I could find little critique, but I did stumble on the following:

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Again note the population size: roughly 25,000,000 residents. The continued comparisons should include at the very least acknowledging these populations.

#23 Comment By Logan On May 9, 2017 @ 6:38 pm

I’d like to see as a Nation we risk pool together, have each others back in case we get sick. There are ways to implement free market reforms within that single risk pool framework, and that is to assign a deductible amount for each American that they are responsible for, before the National risk pool pays a dime- we could base it on income for example, if you make a bunch you pay a larger deductible, if you’re poor you have a relatively small one to cover…. but it would important that everyone pay out of pocket at least something, hence encouraging people to weigh consumption decisions and seek out then best price and quality provider for the services- providers would be forced to publish pricing readily, and give detailed accurate estimates for the decision making process.

I am usually on the side of the private sector doing it better than the government, but this is one case where I think using a large lever to organize and systematize the process makes sense.

I doubt we’ll do this, we seem pretty intent of doing this the most difficult, most expensive way…