W C. Fields had it right – “If at first you don’t succeed, try, try again. Then quit. There’s no point in being a damn fool about it.”
Of course Fields real name was William Claude Dukenfield and he drank a lot, and that finally killed him, but everyone agrees that he was a fine fellow. He wasn’t really a curmudgeon. That was efshtick. He came from vaudeville. Everyone had a shtick – but he didn’t suffer fools gladly. In his will there was a clause leaving a portion of his estate to establish a “W. C. Fields College for Orphan White Boys and Girls, where no religion of any sort is to be preached.” There was no point in being a damn fool about religion either. When something isn’t working, and is never going to work, do the sensible thing – quit. Move on.
House Republicans are apparently ready for yet another attempt to snatch health insurance away from constituents who need it. Someone should remind Speaker Paul Ryan of a saying often attributed to his legendary predecessor Sam Rayburn: “There’s no education in the second kick of the mule.”
Sam Rayburn sounds a lot like W. C. Fields. The two were born two years apart – 1880 and 1882 – so maybe there was something in the air back then. Or maybe the fools were more obviously fools back then – easier to spot – but Donald Trump and Paul Ryan seem to want that second kick of the mule:
President Trump is pushing Congress toward another dramatic showdown over the Affordable Care Act, despite big outstanding obstacles to a beleaguered revision plan and a high-stakes deadline next week to keep the government running.
The fresh pressure from the White House to pass a revision was met with skepticism by some Capitol Hill Republicans and their aides, who were recently humiliated when their bill failed to reach the House floor for a vote and who worry now that little has changed to suggest a new revision would fare any better.
They’re familiar with Sam Rayburn’s mule, but Trump isn’t:
The effort reflects Trump’s sense of urgency to score a victory on Obamacare replacement and move on to other legislative objectives, notably tax restructuring. Passing an Affordable Care Act revision would also allow the president to show progress toward a major campaign promise as he completes his first 100 days in office.
“The plan gets better and better and better, and it’s gotten really good, and a lot of people are liking it a lot,” Trump said at a news conference Thursday. “We have a good chance of getting it soon. I’d like to say next week, but we will get it.”
Right – and everyone will get a unicorn too – or not:
Congressional Republicans also worry that they must attract Democratic support to fund the government past the month’s end – a step they must take by midnight April 28 to avoid a shutdown. That could become difficult if Democrats grow alienated by the effort to alter former president Barack Obama’s key domestic policy achievement, which some White House officials said they hope will come up for a vote as early as Wednesday.
Several congressional GOP aides, who spoke on the condition of anonymity to talk openly about the ongoing negotiations, said they worry that the rushed process threatens to create another embarrassing public failure over health care. The schedule would also make it nearly impossible for lawmakers to finish their work in time for official scorekeepers to provide a clear estimate of how much the legislation would cost or how it would affect coverage numbers.
It may be time to move on, but they won’t move on:
The fresh hopes for resuscitating the American Health Care Act are pegged to an amendment being offered by Rep. Tom MacArthur (R-N.J.) that aims to attract enough conservatives and moderates that the measure can pass in the House. White House officials said language would be circulated among members in the next few days, and the modifications will be discussed Saturday in a conference-wide call as Republicans prepare to return to Washington next week.
The MacArthur amendment would allow states to obtain permission from the federal government to write their own list of essential health benefits and allow insurers to charge people with preexisting conditions higher premiums, as long as they also make a high-risk pool available to those patients – a change conservatives have demanded.
As a concession to moderates, the amendment would also add back federal requirements for essential health benefits, which the measure’s current version instead leaves up to states.
That’s where they were the last time, and many of them know it:
Apart from the publicly embarrassing struggle to reach consensus on an Affordable Care Act revision, some Republicans are also uncomfortable with refocusing on health care just as they are trying to build goodwill with Democrats to pass a stopgap budget plan to keep the government open past April 28.
Republican leaders have already admitted that they are unable to craft a spending bill that can appease the far-right flank of the GOP, and they have turned to Democrats to deliver votes instead. Democrats have so far been willing to work with Republicans to avoid a government shutdown, but any effort to schedule a vote to repeal the Affordable Care Act could destroy those talks and threaten a government shutdown that Republicans have vowed to avoid.
“There isn’t going to be a warm, fuzzy feeling,” House Democratic Caucus Chairman Joseph Crowley (D-N.Y.) said of the impact a health-care repeal effort would have on spending talks.
Try, try again, then quit – there’s no point in being a damn fool about it – but they have their own damn fool in charge:
Trump’s position on a health-care overhaul appears to have shifted in the weeks since the House GOP’s proposal, called the American Health Care Act, failed last month. Then, the president indicated that he was ready to move on to his next priorities, notably tax reform.
Now, Trump is bringing a new urgency to the task of delivering one of his central campaign promises. Additionally, with the 100-day mark of his presidency approaching, he and his senior aides are eager to show a concrete legislative achievement.
Greg Sargent puts that this way:
Naturally, giving President Trump something to arbitrarily tout as an achievement (even if it passes the House, the Senate looms) in advance of the arbitrary 100-day mark is far more important than the human toll the proposal would have on millions.
But the toll of the new plan is considerable:
It allows states to seek a waiver to get rid of the Affordable Care Act’s prohibition on charging higher premiums to people with preexisting conditions, on the condition that states set up or participate in high-risk pools that would help cover any of those people who lose insurance. It would also restore to the GOP bill the ACA’s requirement that insurers cover Essential Health Benefits (EHBs) – such as doctor’s and emergency room visits and maternity care – but allow states to seek waivers from them.
In effect, the waiver on preexisting conditions is designed to make conservatives happy, while giving moderates high-risk pools that allow them to argue it wouldn’t harm people with preexisting conditions. The restoration of EHBs is designed to make moderates happy, while telling conservatives states could still get out from under them.
But the waiver on prohibitions against jacking up premiums for people with preexisting conditions – which is called “community rating” – is a major problem. It would smack them with far more in costs — potentially pushing them off coverage entirely.
Sargent provides a nifty table documenting the specifics, for policy wonks, but it comes down to this:
Topher Spiro, a health policy analyst at CAP, tells me that these sums were calculated by using actuary “risk scores” for each condition, which detail how much someone with that condition costs insurers relative to a healthy person.
“If insurers can charge sick people higher premiums than healthy people, they would add a surcharge to premiums that reflects this additional cost,” Spiro says. “The premium markups would be unimaginable, adding thousands or even tens of thousands of dollars to premiums. They would be priced out of the market and quarantined into high-risk pools.”
Now, in fairness, these findings are based on calculated national averages, so applying them to what would happen in any given state is tricky. But this is intended as a general guideline of what sort of premium hikes we might see in states that did seek waivers – and it’s fair to assume many red states would do so. What’s more, this conclusion dovetails with the general conclusions of other health policy analysts. The big story is that, while the new plan would ostensibly keep the prohibition against refusing to cover people with preexisting conditions, allowing premiums to be jacked up would functionally price a lot of those people out of the market, gutting that protection.
This is far worse than the last time around:
Indeed, the nonpartisan Kaiser Family Foundation’s Larry Levitt tells me he thinks the CAP projections are plausible. “These figures show why a guarantee of coverage without community rating offers essentially no protection for people with pre-existing conditions,” Levitt says. “No insurance company will want to cover people with expensive health conditions if they don’t have to, so they will set premiums to make sure the coverage is out of reach. Health care costs are highly concentrated among a small number of people who are sick, and they would find it impossible to get affordable coverage.”
Of course, the new plan’s defenders would reply that these people can go into high-risk pools (this is apparently meant to give moderates cover to back it). But they’ve historically been underfunded and/or resulted in people paying higher prices or going without coverage.
But wait, there’s more:
Meanwhile, the new GOP plan would keep in place the old plan’s phase-out of the Medicaid expansion, which would itself result in 14 million fewer people on Medicaid, according to the Congressional Budget Office. You’d think that this, plus the gutting of protections for preexisting conditions, would render the new plan toxic for GOP moderates who, in rejecting the old plan, have confirmed that they are not willing to embrace a massively regressive plan that would push millions of poor and sick people off coverage while delivering an enormous tax cut to the rich. Of course, the need to give Trump a fake achievement to tout is also an urgent matter, so who knows what they’ll do?
They could stop being damn fools. Let it be. There really is no education in the second kick of the mule, and Eugene Robinson explains that kick:
Republicans don’t talk much about the practical reason for moving urgently on health care, which is to set the stage for tax reform: They want to take money now used to subsidize health care for low-income Americans and give it to the wealthy in the form of big tax cuts. Again, we can see you.
I’m sure the crowds at GOP town halls will be understanding. Just be sure to check attendees at the door for tar and feathers.
The crowds at GOP town halls will see this:
We would go back to the pre-ACA situation in which serious illness could mean losing a home or filing for bankruptcy.
This may satisfy GOP ideological imperatives – Ayn Rand would be so proud – but it is atrocious policy, even if you put aside considerations such as compassion and community.
And there’s this:
We live at a time of enormous economic dislocation. The manufacturing sector has shrunk dramatically, and now retail may be starting down the same path; long-lost jobs in industries such as coal mining are not coming back, no matter what Trump says. Workers need to be able to move to where jobs are being created – which means that health insurance should ideally be portable. But Republicans are heading in the other direction by trying to set up a system with radically different health-insurance rules in different states. In today’s world, how does that make sense?
And there’s this:
Unchanged from last month’s failed bill are provisions that would strip massive amounts of money out of Medicaid, by far the nation’s biggest source of payment for nursing-home care. So Republicans might not want to show their faces anywhere near retirement communities.
They’re asking for trouble, for that second kick from Sam Rayburn’s hypothetical mule, but that’s the plan:
The Affordable Care Act changed the way most people in this country think about health care. It did not, however, change the thinking of many House Republicans, who continue to believe individuals should be held financially liable for a genetic predisposition toward diabetes or a random cellular mutation that leads to cancer.
Not everyone feels that way. Ezra Klein argues that the Republicans’ biggest health care achievement has been making Obamacare more popular:
It is bizarre watching House Republicans persuade themselves that the problem they face on health care is cutting a deal between the Freedom Caucus and the Tuesday Group rather than crafting legislation that people actually like, and that will actually make some part of the health care system noticeably better. But the GOP’s refusal to take public opinion even mildly into account has put them in a disastrous position.
I’m not sure Republicans realize how deep a hole they’re in on this issue. But here’s a way to make it clear. Obamacare is now significantly more popular than Donald Trump, Mike Pence, Paul Ryan, the Republican Party, or the American Health Care Act.
The aggregate approval numbers from all the polling are a bit sobering – Obamacare at 55 percent, Mike Pence at 49 percent, the Democratic Party at 45 percent, the Republican Party at 40 percent, Donald Trump at 39 percent, Congress at 34 percent, Paul Ryan at 29 percent, and the new American Health Care Act at 17 percent – before these latest possible revisions.
The Republicans’ strategy, right now, is to replace a law that’s more popular than they are with a bill that was polling at 17 percent before it went down in flames. And their approach to doing that isn’t a new campaign where they persuade the public that the AHCA is a good idea, nor is it a new proposal that fixes the problems that made the old bill so unpopular.
Instead, it’s a backroom deal that changes the AHCA so it’s easier for insurance companies to charge sick people more for coverage. Is that really what Republicans think the public disliked about the original bill? That it made it too hard for insurers to turn away former cancer patients?
The mule has already kicked them, twice:
When Democrats passed Obamacare, the law was mildly unpopular (though nothing close to the AHCA’s catastrophic numbers), but they believed, firmly, that it would grow more popular as it began delivering insurance to millions of people.
So far, the main thing the new Republican majority has achieved on health care is to prove the Democrats right – they have made Obamacare more popular than it’s been at any other point in its existence. And they’ve achieved that by persuading people disappointed in Obamacare that it’s better than what Republicans want to put in its place.
Josh Barro puts that another way:
I think it is best to understand the periodic reemergence of the American Health Care Act as similar to the periodic searches for evidence that President Barack Obama really did “tapp” Trump’s phones.
Trump says he was wiretapped, so he sets off a frenzy as Republicans seek to substantiate that claim, even though they will never be able to. Trump says Republicans are still making great progress on a healthcare deal, so he also sets off frenzies among Republicans to substantiate that claim, even though they’ll never be able to.
Trump forces his staff and Republicans in Congress to spend energy trying to construct in the real world the alternate reality that exists in his head, even when their energies would be best directed elsewhere – for example, toward trying to reach an agreement on a bill to prevent the government shutdown that will occur, absent legislation, on April 29.
That actually makes sense, but not in the real world:
The problems that prevent Republicans from passing a health care bill remain the same as they ever were.
A substantial number of members of the Republican House conference have maximalist ideas about Obamacare repeal, and can’t abide leaving a lot of the law’s spending and (especially) insurance regulations in place.
A substantial number of other members of the Republican conference have ideological or political objections (or both) to changes that would take away health insurance from many of their constituents, and/or make it difficult for people to get health insurance coverage that addresses their actual medical needs.
Fixing the first group’s objections will only deepen the second group’s objections. The spending the Freedom Caucus hates is what keeps coverage levels high. The regulations they hate are what make sure coverage actually addresses people’s healthcare needs, including pre-existing conditions.
In short, this was never going to work:
Healthcare is more complicated than Trump realized, but it’s not so complicated that you can creatively slice and dice the legislation to address the objections from both the right and the center. It’s impossible to write a bill that gives 216 Republicans in the House something they consider to be politically and substantively acceptable.
Meanwhile, the healthcare bill keeps getting less popular, congressional Republicans keep getting berated about the bill by constituents at town halls, and more members keep responding to that beratement by making promises to ensure the law protects coverage and holds people with preexisting conditions harmless – promises they will break if they vote for a revived version of the bill.
If so, and this seems to be so, there’s only one way to see this:
This bill is dead. Dead, dead, dead, dead, dead, dead, dead. But Republicans will prop up its stinking corpse… until the president allows them to stop.
Donald Trump will not allow them to stop. He’ll be a damn fool about it. He’s not W. C. Fields. In fact, Donald Trump doesn’t drink. Maybe that’s the problem. Donald Trump is out back with Sam Rayburn’s mule.