It was a strange day in American politics. President Trump returned to New York for the first time since he won it all – for a victory speech on the Intrepid – the retired aircraft carrier that’s now a floating museum docked at Hudson Yards on the east side of the river not far from Trump SoHo – one more giant Trump Tower involved in many fraud lawsuits and perhaps financed by Russian mob folks connected to Vladimir Putin. Trump didn’t return to his actual home in Trump Tower just south of Central Park, where his wife and their young son now live. She doesn’t get out much. She doesn’t seem to want to. She’s fine with living in Manhattan. She’s seldom seen in Washington, and when there says nothing. She stands in the background. He does his thing. She smiles. That’s it. The two of them don’t see each other much at all, and that seems fine with her. That also seems fine with him. He’s got Ivanka. She’ll do the first-lady thing.
That made Trump’s return to New York odd, but this was a victory lap, even with all the protesters in the street. Donald Trump had won one third of his first legislative victory – the House had finally passed the American Health Care Act, the revised-beyond-comprehension replacement for Obamacare. Now it goes to the Senate, but the Republicans there say they’re not even going to look at it. They’ll write their own legislation – and then, if they pass that, that goes to conference. That’s the third step – the separate House and Senate legislation has to be reconciled into a single bill that both the House and Senate agree is what this stuff should be – so Trump now has one third of a victory.
He’ll take it, but this was a close-run thing:
House Republicans on Thursday narrowly passed a controversial bill to overhaul the nation’s health-care system, claiming a major victory even as the measure faces an uncertain fate in the closely divided U.S. Senate.
Under intense pressure to show they can govern and to make good on their promise to repeal and replace the Affordable Care Act, Republicans pushed through the bill after adopting a last-minute change that earned it just enough votes to pass. However, the House version fell significantly short of the GOP’s long-held goals, making major dents in large portions of the current law but not outright repealing it.
The bumpy, months-long process that led to Thursday’s vote also violated some of the GOP’s own promises on how they would govern.
The measure proceeded without the benefit of an analysis from the Congressional Budget Office of its cost and impact on insurance coverage, and it did so after many Republicans openly acknowledged that they hadn’t read the bill. President Trump also promised “insurance for everybody,” which the measure will not achieve.
Trump will take that too – it’s a victory – but it’s troublesome:
The House bill would shift power to states to set important health insurance rules. And it would end the ACA’s subsidies for eligible people who buy health plans through marketplaces created under the law, creating and substituting new tax credits. It also would rescind several taxes that have helped pay for the law, including ones imposed on Americans with high incomes, health insurers, medical devices and tanning salons.
Among the bill’s more contentious provisions is one that would allow states to let insurers return to their old practice of charging more to customers with preexisting medical problems – a practice that current law prohibits.
This is a tax cut for the rich that screws the poor, but they were warned:
Before the vote, House Minority Leader Nancy Pelosi (D-Calif.) noted that while many Americans can’t name their member of Congress, Thursday’s vote would earn their ire.
“You will glow in the dark on this one,” Pelosi warned. “So don’t walk the plank, especially unnecessarily.”
They walked the plank anyway:
Every Democrat and 20 Republicans voted against the measure, the latter a mix of ardent conservatives upset that the bill didn’t fully repeal Obamacare and members from suburban swing districts worried about the political fallout. The wide-ranging interpretations of whether the bill would gut the current law – or wouldn’t – are likely to fuel the nature and intensity of that fallout.
For instance, the measure does not eliminate the ACA’s requirement that most Americans carry health insurance, although the penalty for not having coverage would be erased. In its place, insurers would be allowed to charge 30 percent higher premiums for one year to customers who have had a gap in coverage of roughly two months or more.
Medicaid would also be transformed in two ways. For the 31 states that expanded the safety-net program under the ACA to include people with slightly higher incomes, the government would immediately stop paying for anyone new to enroll under the expansion and would eventually stop the extra federal money that came with the expansion. Starting in a few years, Medicaid would also end its half-century tradition as an entitlement program in which the government pays a certain share for each person who enrolls, switching instead to a “cap” with a fixed amount per person.
That really screws the poor, and Paul Kane reports this:
Republicans pushed a health-care bill through the House Thursday that few lawmakers truly liked. They instead viewed the measure as a necessary step to demonstrate some sense of momentum and some ability to govern in GOP-controlled Washington.
Rather than embrace policy cobbled together to replace the 2010 Affordable Care Act, many Republicans simply decided the best move was to approve a flawed bill – and ram it through a flawed process – so that the Senate would get a chance to fix the House’s mistakes, setting up a major negotiation later.
They simply wanted to wash their hands of this, but like in the old crime movies, they might not be able to wash the blood from their hands:
House Republicans did so knowing that their votes will be portrayed by their Democratic opponents as ruthlessly denying millions of people health insurance and causing Americans with preexisting illnesses to shoulder higher costs.
And they did so knowing that there’s a chance the Senate will choke on the legislation or that House and Senate negotiators will deadlock and never agree to a final product – leaving them on record voting for a bill that could have career-ending consequences.
But some things are more important:
The other critical factor was a desire for the House GOP majority to show it can actually govern.
Inside the leadership team of House Speaker Paul D. Ryan (R-Wis.), there was a gripping fear of what failure would mean for its future overseeing a chamber seemingly incapable of moving important legislation. Ryan had already pulled his American Health Care Act from the floor once, in late March, amid a rebellion on his left and right flanks regarding its shortcomings.
The initial game plan was to simply give up on repealing Obamacare and move on to a broad rewriting of the tax code. But inside the White House, President Trump’s advisers became increasingly concerned about how little they had to show in terms of early victories. They helped nudge the hardline House Freedom Caucus and some members of the moderate Tuesday Group back to the bargaining table.
Lawmakers produced a deal that eventually brought all but one member of the Freedom Caucus into the fold, and Ryan’s team realized it was as close as Republicans had been to passing the legislation. At that point, wavering members faced pressure to be loyal to the speaker and show that the House could act.
The consequence of failure – for a second time in six weeks, after the humiliating first retreat – became a compelling reason to vote “yes.”
Now they won’t face the consequences of failure, but Kane notes that they do face this:
The legislation passed by the narrowest of margins, 217 to 213. Twenty Republicans opposed the legislation, at a time when independent political analysts rate about 40 GOP seats as potentially vulnerable in 2018. If Republicans lose 24 seats, they lose the majority.
A couple of dozen Republicans took risky votes on legislation that, so far, has not proved to be particularly popular among voters.
There was no good option, but maybe the Senate will screw up and everyone will forget what they did. There’s hope there, but Kevin Drum brings this down to earth:
Will today’s vote finally be enough to get Democrats – and lefties in general – to finally defend Obamacare loudly and vigorously? Or is it still going to be the same old tired there is no question that Obamacare wasn’t perfect, but…?
Note to members of Congress: sure, Obamacare should be more generous and subsidies should be higher. But you don’t need to harp on it. It’s covered 20 million people! It cost less than projected! It’s slashed medical bankruptcies! It forced insurers to cover people with pre-existing conditions! It’s great!
Note to lefties: sure, Obamacare should have included a public option and it should have been more generous. Hell, in a different, better universe it would have been universal single-payer. But just let it go. Obamacare has covered 20 million people! It cost less than projected! It’s slashed medical bankruptcies! It forced insurers to cover people with pre-existing conditions! It’s great!
Drum knows that’s not going to happen:
Like Trump, Republican politicians just say whatever they want. There’s no longer any pretense of retaining even a nodding acquaintance with the facts. TrumpCare is going to benefit the rich. No it won’t. TrumpCare will do away with protections for pre-existing conditions. No it won’t. TrumpCare will rob 24 million people of health coverage. No it won’t. TrumpCare will take Medicaid away from the poor. No it won’t.
That’s it. Just make the assertions and then sign off. TrumpCare is going to cover everyone, it bans any discrimination based on pre-existing conditions, it will make health care more affordable, it will reduce deductibles, and it will be great for older people. Gotta go now. Thanks for having me on your show.
I’m not even sure anymore what you do about this. Is it even lying per se? The sky is green. Scientists say it’s blue. It’s green. It’s always been blue. It’s green. I just looked out the window. It’s blue. It’s green. It’s right here on my monitor. It’s green. Thanks for the interview, congressman.
Expect a lot of that, but Josh Barro adds more detail:
The most important political effect of Thursday’s vote may then be that nearly the entire House Republican conference is now on the record for the proposition that health insurers should be able to charge patients more if they have preexisting health conditions.
In fairness to Republicans, that’s how most insurance products are priced: If your house is located on the oceanfront, you’re going to pay more for coverage against hurricanes. But the widespread unpopularity of medical underwriting (that is, the practice of charging people more if they’ve had cancer, etc.) reflects a public consensus that health risks are different from other kinds of risks; that the financial costs associated with them are appropriately pooled across the population instead of stuck disproportionately on the people most likely to need medical care.
Being at elevated risk for cancer is misfortune enough; it shouldn’t also come with the obligation to pay a whole bunch of extra insurance premiums.
Most people seem to believe that, and that’s the problem:
Preexisting condition coverage is a visceral issue on which House Republicans will have to defend themselves in next year’s elections to an electorate that really doesn’t like the stance they have taken. And they’ll have to justify their choice to party in the Rose Garden with a very unpopular president right after they voted to do so.
Yeah, there was that party, and Ashley Parker reports on how that went down:
President Trump clapped and pointed. He grinned and nodded. He mouthed praise and boomed exultations.
He even, at one point, turned his back to the lectern to face the House Republican leadership, tossing his arms wide in open embrace before swooping his index fingers above the crowd – as if conducting a symphony of recalcitrant lawmakers who had finally, haltingly, learned how to harmonize.
For a president deprived of signature legislation so far, Thursday’s Rose Garden ceremony for the Republican health-care plan was the sweetest victory.
But before that, there was this:
Trump watched the vote count tick up on the flat-screen television in the presidential dining room just off the Oval Office, huddled with a small group of his senior team: Vice President Pence; Jared Kushner, his son-in-law and senior adviser; daughter Ivanka Trump; Stephen K. Bannon, his chief strategist; communicators director Hope Hicks; senior economic adviser Gary Cohn; Dina Powell, deputy national security adviser for strategy; counselor Kellyanne Conway; and Transportation Secretary Elaine Chao, who is married to McConnell.
The president, said one senior White House official, was calling lawmakers right up until the vote began, thanking some and cajoling others. The legislative affairs team even set up a special phone booth in the House cloakroom so members could receive calls from the president and his deputies.
When the bill passed, the West Wing crew exchanged applause, handshakes and congratulations, but nothing over the top, said one senior administration official. Another described the mood as “businesslike.”
That didn’t last long, because they moved on to the Rose Garden:
A Marine quartet sat playing on the lawn – the same tableau as the day last month when Neil M. Gorsuch became a Supreme Court justice. Lawmakers snapped photos and clapped each other on the shoulder. White House press secretary Sean Spicer even raced back from his Navy Reserve duty at the Pentagon to savor the moment…
Trump basked in adulation as lawmakers heaped praise on him. Ryan touted his leadership, thanking Trump and Pence for “working to get this right, for getting this done and getting us to where we are.” Rep. Mark Meadows (R-N.C.), chairman of the conservative House Freedom Caucus, heralded Trump as “a president who wouldn’t give up, a president who got engaged.” And Health and Human Services Secretary Tom Price told the president, “I want to thank you from the bottom of my heart for the privilege of being on your team.”
And Trump – who earlier in the process expressed surprise at just how complicated health-care could be – also seemed momentarily in awe of the day.
“How am I doing?” he asked, before answering his own question and posing another. “I’m president. Hey, I’m president. Do you believe it, right?”
He seemed more surprised at that than anyone there, probably because of what Philip Bump notes here:
It was one thing for Donald Trump to pledge on the campaign trail that his plan for health care would assure that every American had coverage. He did so repeatedly, including during a town hall event in February 2016 at which he said his promise to “take care” of everyone might sound as if he was talking about a single-payer system, but he wasn’t. “That’s not single-payer,” he said. “That’s not anything. That’s just human decency.”
It was another thing, though, for Trump to make similar claims after the election. Before the election, it was anything goes in a way that most politicians would avoid. Afterward, one might expect Trump to zero in on his preferences a bit more narrowly, to scrape away the rhetoric and describe, instead, what it was that he wanted to see.
“We’re going to have insurance for everybody,” Trump told The Washington Post’s Robert Costa and Amy Goldstein during an interview less than a week before his inauguration. Although Trump was characteristically confident and equally characteristically light on specifics, he did outline several things that he anticipated the Republican replacement bill for the Affordable Care Act might include.
The plan would have “lower numbers, much lower deductibles – the philosophy in some circles that if you can’t pay for it, you don’t get it”? Trump insisted that “that’s not going to happen with us” – implying that there would be universal coverage regardless of income. What’s more, people could “expect to have great health care” that would be “in a much simplified form. Much less expensive and much better.”
Trump told Costa and Goldstein that people wouldn’t keep their existing plans but would have some sort of insurance plan. “They’ll be beautifully covered,” he said. “I don’t want single-payer. What I do want is to be able to take care of people.”
Fine, but the job changed things:
Trump promised insurance for everybody. The AHCA would probably result in 24 million more uninsured people by 2026, according to the Congressional Budget Office’s analysis of the original GOP bill.
Trump promised lower “numbers” and lower deductibles. The AHCA would probably have higher deductibles. The CBO anticipates that they will be higher under the AHCA than they would have been if the ACA were kept, thanks to a change in the actuarial values used in determining plan costs.
Trump promised “much less expensive” coverage. The AHCA would probably mean that customers would eventually see lower premiums – after premiums increased, pricing more-expensive patients out of the market.
Trump promised that people who can’t pay for coverage would still receive coverage. The AHCA would probably reduce the number of lower-income people with coverage. This is in part because they will receive less government support to pay premiums. It’s also in part because the Republican bill cuts funding to Medicaid, meaning that millions fewer people would be covered under the program.
Trump promised that policies would be “much better” and that people could expect to have “great health care.” The AHCA would probably reduce the quality of insurance plans, thanks to late amendments that would allow states to get waivers so that insurers could separate coverage items out of the default package. The cost of plans would go down – but people who find themselves needing coverage for something that had been removed would end up paying much more.
Donald Trump may be president, even if he still can’t quite believe that, but there’s another reality:
Trump’s promise to cover everyone more broadly and for less money was always an impossibility, akin to saying that you were going to have your cake, eat your cake – and give everyone in America the same cake, which would feed them forever.
Theresa Brown slowly and carefully explains why that is so:
First, health care in the United States costs much more than in other developed countries, and on average the outcomes are worse. Second, any plan that focuses primarily on reducing the cost of insurance will inevitably lead to less access to care. Indeed, whatever Republicans say about high-risk pools and other ways their plan covers vulnerable people, the fact is that millions will lose coverage.
This isn’t that hard to explain:
Health care in the United States is more expensive because, unlike the systems in other countries, ours rests on the idea that profits and quality health care go hand in hand. As a result, government programs working with our existing structure of for-profit insurance companies can expand and improve coverage (like the Affordable Care Act) or offer lower insurance premiums (like the new Republican plan). But they can’t do both.
Supporters of the ACA, also known as Obamacare, talked a good game about “bending the cost curve,” but that was never a primary concern. The goal, largely achieved, was to expand access and to mandate coverage for essential health benefits and pre-existing conditions.
In contrast, the thrust of the Republican bill is to lower the cost of insurance by removing the guarantees of the ACA. States would be able to exempt any of the essential health benefits from insurance mandates, and they would also be allowed to exclude patients with pre-existing conditions. Millions are likely to lose their health insurance, but the young and generally healthy would pay much lower premiums.
In short, the two plans are not different takes on the same problem. They are different takes on different problems.
This means that everything depends on which problem you choose to address:
Yes, the price of insurance is an issue – though a properly designed plan will at least move most of those costs off individuals and small businesses and onto the government’s shoulders.
Access to quality care, in contrast, is literally a matter of life and death (and, of course, costs to those no longer covered). And not just for the newly uninsured. One principle behind the Republican plan is that patients, as consumers, should pay only for what they need: The sick need more coverage and so pay more (possibly with a small amount of federal subsidies), and vice versa for the healthy.
That may be where there’s a basic misunderstanding:
Broadly speaking, “sick” and “healthy” are not fixed qualities. The whole idea behind insurance is that anyone healthy can get sick, and so everyone should have the same coverage. When the H1N1 flu virus struck a few years ago, many of the sickest patients were otherwise reasonably healthy adults, who survived only because of intensive care, often costing well over $5,000 a day.
I think we would all agree that such care is worth what it costs, though, since essentially healthy people went to the hospital dangerously ill and left restored. The ACA mandates such coverage, even though it means everyone’s insurance will be more expensive. The cheaper, non-comprehensive insurance policies allowed by the new Republican health care bill might not cover such situations.
That’s the problem with the Republican plan, but not the only problem:
It promises to reduce the price of insurance, and it may do that for some people. But it won’t make much of a dent in the overall price of health care, because it doesn’t deal with the fundamental reasons it is so expensive: the profit-driven nature of the system.
For better or (mostly) worse, the American health care industry is a largely for-profit sector. Health care is expensive because companies have to charge more to maintain revenue…
In this context, the new Republican health care plan is a ruse: Less pricey health insurance that does not actually make health care less expensive, while eliminating the Obamacare protections, is likely to cause millions of Americans to lose their health insurance altogether.
Every other industrialized country offers health care that is cheaper and better, because they use government controls to balance revenue generation and the costs of meeting patients’ needs.
That means that the Republican plan gets this backwards:
If Republicans really want cheaper insurance policies to equal quality care, then they need to guarantee coverage, and make that affordable by reining in health care profits. Because getting cheaper insurance at the expense of endangering one’s life is not a health care bargain.
Theresa Brown needs to explain that slowly and carefully to Donald Trump, while others slowly and carefully explain to him that this wasn’t a victory, it was one third of a possible victory. What’s he going to say to that?
Everyone knows what he will now say to that. “Hey, I’m president!”
He is, but there’s a reason that he’s so surprised by that. Melania Trump seems surprised too, and she’s hiding.