Not Getting It Done

There was trouble coming. President Trump had a bad weekend. It was that Washington Post-ABC News poll:

Approaching six months in office, Trump’s overall approval rating has dropped to 36 percent from 42 percent in April. His disapproval rating has risen five points to 58 percent. Overall, 48 percent say they “disapprove strongly” of Trump’s performance in office, a level never reached by former presidents Bill Clinton and Barack Obama and reached only in the second term of George W. Bush in Post-ABC polling.

It took the second George Bush almost seven years to sink to this level – so Donald Trump is the only one who ever sank this low this fast in seventy years of presidential polling – and there was this:

As Republican senators attempt to pass major health-care legislation, the poll finds about twice as many Americans prefer the Affordable Care Act, otherwise known as Obamacare, to GOP plans for replacing it – 50 percent to 24 percent.

Half the nation wants to keep Obamacare, given the nasty replacement the Republicans are proposing. Less than a quarter of the nation wants that, whatever it is – the details keep changing – because they get the general idea:

On one key issue in the debate over the Republican plan, the public by 63 to 27 percent says it is more important for the government to provide health coverage to low-income people rather than cutting taxes. Republican proposals include major reductions in spending increases for Medicaid, while eliminating many taxes and fees imposed by the 2010 Affordable Care Act to expand the program.

The general idea is that the rich shouldn’t get richer off the backs of the elderly, the disabled, the poor, and the unlucky. Obamacare offered light central planning of a system that subsidized the purchase of standardized healthcare policies from the for-profit insurance industry – paid for by slightly higher taxes on the rich folks. It was an awkward half-free-market hybrid that also included expanding Medicaid to cover those who couldn’t even afford subsidized policies, but it worked, and is working. Half the nation knows that. Less than a quarter of the nation thinks the rich folks have been treated unfairly in all this.

That makes any replacement for Obamacare a hard sell. What’s the alternative? Why is it better? That calls for deep policy discussions about the details of funding, and just what would be funded, and why – which is a discussion of the proper role of government in relation to personal responsibility, and the relationship of personal responsibility to the social contract, if there is such a thing. It’s complicated.

Donald Trump doesn’t sweat the details – not those details. He has no particular thoughts about any of this at all. He just wants a win. One major piece of legislation would be nice.

He’s a bit sensitive about that:

To hear President Trump tell it, his first six months in the White House should be judged in part by the legislation he has signed into law.

At rallies, in speeches and on Twitter, Mr. Trump repeatedly boasts of the bills he has signed – 42 as of this week. He has said no president has “passed more legislation,” conceding once earlier this year that he trails Franklin D. Roosevelt, who he notes “had a major Depression to handle.”

On Monday, he went even further, claiming to have bested all of his predecessors in turning bills into law.

“We’ve signed more bills – and I’m talking about through the legislature – than any president, ever,” Mr. Trump said at a “Made in America” event at the White House. “For a while, Harry Truman had us. And now, I think, we have everybody.”

Ah, no:

An analysis of the bills Mr. Trump signed shows that about half were minor and inconsequential, passed by Congress with little debate… 15 reversing Obama regulations, 14 ceremonial and routine lawmaking, 5 bureaucratic tweaks, 4 space and science bills, 4 veterans bills…

His aides note that Mr. Trump has used executive orders, such as his ban on travel to the United States for refugees and those living in some Muslim countries, to get around what they say is unprecedented obstruction by Democrats. And he successfully won confirmation of Neil M. Gorsuch to the Supreme Court.

But almost half the other bills Mr. Trump has signed into law are ceremonial or routine. The president includes in his count laws like the one to rename the federal courthouse in Nashville after Fred Thompson, the actor and former senator who died in 2015. Even the Republican leadership in the Senate does not count those kinds of bills when they tally their legislative achievements.

By contrast, Mr. Trump’s tally includes three laws to appoint members to the Smithsonian Board of Regents, another to seek research into better weather reports, and one to require the Department of Homeland Security to manage its fleet of vehicles more efficiently.

The Department of Homeland Security should manage its fleet of vehicles more efficiently, and sleepy Fred Thompson was a fine fellow, but one major piece of legislation would be nice. It’s time. It was going to happen, and then it all fell apart:

Two more Republican senators declared on Monday night that they would oppose the Senate Republican bill to repeal the Affordable Care Act, killing, for now, a seven-year-old promise to overturn President Barack Obama’s signature domestic achievement.

The announcement by the senators, Mike Lee of Utah and Jerry Moran of Kansas, left their leaders at least two votes short of the number needed to begin debate on their bill to dismantle the health law. Two other Republican senators, Rand Paul of Kentucky and Susan Collins of Maine, had already said they would not support a procedural step to begin debate.

Donald Trump will not get his one major piece of legislation, or anything at all:

With four solid votes against the bill, Republican leaders now have two options.

They can try to rewrite it in a way that can secure 50 Republican votes, a seeming impossibility since the defecting senators are not suggesting small changes to the existing bill but a fresh start. Or they can work with Democrats on a narrower measure to fix the flaws in the Affordable Care Act that both parties acknowledge.

Senator Mitch McConnell, the Republican leader, conceded Monday night that “the effort to repeal and immediately replace the failure of Obamacare will not be successful.” He outlined plans to vote now on a measure to repeal the Affordable Care Act, with it taking effect later. That has almost no chance to pass, however, since it could leave millions without insurance and leave insurance markets in turmoil.

And that called for a tweet:

President Trump was not ready to give up. He immediately took to Twitter to say: “Republicans should just REPEAL failing ObamaCare now & work on a new Healthcare Plan that will start from a clean slate. Dems will join in!”

They will? The idea here seems to be to get rid of Obamacare right now, and with no possible Trumpcare at all now, people would be dying in the streets left and right, so the Democrats would have to join in, in coming up with something. In short, force their hand.

That doesn’t solve the essential problem:

In announcing his opposition to the bill, Mr. Moran said it “fails to repeal the Affordable Care Act or address health care’s rising costs.”

“There are serious problems with Obamacare, and my goal remains what it has been for a long time: to repeal and replace it,” he said in a statement.

In his own statement, Mr. Lee said of the bill, “In addition to not repealing all of the Obamacare taxes, it doesn’t go far enough in lowering premiums for middle-class families; nor does it create enough free space from the most costly Obamacare regulations.”

By defecting together, Mr. Moran and Mr. Lee ensured that no one senator would be the definitive “no” vote.

These two care about policy, and there are other concerns:

Mr. McConnell was trying to sell legislation that was being assailed from many directions. On Friday, the health insurance lobby, which had been largely silent during the fight, came off the sidelines to blast as “unworkable” a key provision allowing the sale of low-cost, stripped-down health plans, saying it would increase premiums and undermine protections for people with pre-existing medical conditions.

That was never going to work:

Mr. Lee, one of the most conservative members of the Senate, was part of a group of four conservative senators who came out against the initial version of Mr. McConnell’s bill after it was unveiled last month. He then championed the proposal to allow insurers to offer cheap, bare-bones plans, which was pushed by another of those opponents, Senator Ted Cruz of Texas. But the language ultimately added was not quite what Mr. Lee had been advocating, a spokesman said last week.

Lee is a picky fellow, but there was this too:

Mr. Moran, a reliable Republican vote and a past chairman of the Senate Republicans’ campaign arm, had announced his opposition to the bill as drafted after Mr. McConnell scrapped plans to hold a vote in late June. He expressed concerns about how it would affect Kansas, including whether it would limit access to health care in rural communities and effectively penalize states, like his, that did not expand Medicaid under the Affordable Care Act.

The pressure on Mr. Moran at home showed no sign of relenting. The Kansas Hospital Association said last week that the revised Senate bill “comes up short, particularly for our most vulnerable patients.”

Politico reports that Trump didn’t get it:

At a dinner with GOP senators on Monday evening, Trump said the party would look like “dopes” if they couldn’t pass the bill after passing a repeal bill in 2015.

“If the Republicans have the House, Senate and the presidency and they can’t pass this health care bill they are going to look weak,” Trump said, according to a source familiar with the meeting. “How can we not do this after promising it for years?”

Trump had no idea defections were coming tonight, according to another White House official with knowledge of the meeting. “Why would we have a dinner like that if we knew people were going to drop out?” the official said.

They should have known:

Even before Lee and Moran’s announcement, there were increasingly urgent signs that the GOP’s 52-seat majority was too fragile to pass the bill, which would scale back Medicaid spending and Obamacare’s insurance subsidies… Sen. Ron Johnson (R-Wis.) had fumed that McConnell had committed a “breach of trust” in selling the bill to moderates…

Johnson was stunned to read in The Washington Post that McConnell was privately arguing that major reforms to Medicaid were so far in the distance that they would never take effect. Johnson said Monday that he’d confirmed through conversations with other senators that McConnell had made the remarks.

“The reported comments from Leader McConnell before last Thursday about ‘don’t worry about these Medicaid changes, they won’t take effect,’ that’s troubling to me. I have talked to senators that basically confirmed that. I’ll see what Leader McConnell says tomorrow,” Johnson said on Monday evening. “From my standpoint, it’s a pretty serious breach of trust, those comments. I’m just troubled by those comments.”

Mitch McConnell was having a bad day too, but Matthew Yglesias notes this:

The Better Care Reconciliation Act (BCRA) is dead. But the cause of Obamacare repeal is very much still alive. And the cause of preserving its coverage gains – and the welfare of the millions of people who gained insurance thanks to the Affordable Care Act – has now entered a new and dangerous phase.

The problem, fundamentally, for people who care about health insurance coverage is that of the four Republican defectors only one – Collins – objects to the bill on the grounds that it doesn’t cover enough people.

The other three are complaining, fundamentally, that the bill isn’t “real” Obamacare repeal or doesn’t go far enough. For people’s coverage to be safe, something else has to happen. One or two or three or more of the Republican members who’ve raised concerns about coverage losses need to join Collins in squarely promising to vote against a bill that causes massive coverage losses.

Then they could either leave the ACA in place, or else start working with moderate Democrats on bipartisan revisions to the bill that would be aimed at improving American health care rather than rolling back insurance coverage. Until then, the Affordable Care Act is very much under threat.

This isn’t over:

The real fate of American health care lies with five Republicans – Dean Heller (R-NV), Shelley Moore Capito (R-WV), Rob Portman (R-OH), John Hoeven (R-ND), and Lisa Murkowski (R-AK) – whose behavior since McConnell rolled out BCRA 2.0 has been strange.

These five all clearly and unambiguously stated that the Medicaid cuts in BCRA 1.0 were too severe. But then McConnell went back to the drawing board and came up with a new piece of legislation that made no changes whatsoever to the Medicaid provision. At that point, you would expect everyone who called the Medicaid provision a deal-killer to say no to the new bill. And that is, in fact, what Collins did. But the other five have all proclaimed themselves undecided and have made themselves scarce.

With the bill now dead again thanks to objections from the right, the moderates will probably come out of the woodwork again and announce that they oppose it too. But the pattern we saw in the House was that once the Freedom Caucus was fully on board with the leadership’s plans, moderates lacked the backbone to actually kill the bill.

That could happen again, and on the other side there’s this:

The idea of blocking this law for right-wing reasons makes relatively little sense.

BCRA cuts taxes, cuts regulation, cuts spending, and cuts the deficit. It may not go as far on some of those items as conservatives would like, but it’s clearly a conservative bill. The big problems with it are that precisely because it cuts taxes, cuts regulation, cuts spending, and cuts the deficit it will leave millions of Americans without insurance and millions more with skimpier plans and higher deductibles. But that again simply goes to show that at the end of the day this is a profoundly conservative bill that it would be perverse for conservatives to kill.

One possible exception to that is Paul, whose home state of Kentucky is very low-income and embraced the ACA’s Medicaid expansion – meaning Obamacare repeal would, in a concrete sense, be an economic catastrophe for his constituents. From the beginning many have suspected Paul of playing what David Frum labeled a “denounce and preserve” strategy of offering fake-conservative objections rather than admitting that Obamacare is good for Kentucky.

But the other conservatives seem more like they’re angling for a better legislative deal – perhaps a more rapid phase-in of Medicaid cuts or steeper tax cuts – rather than raising fundamental objections.

The two new “no” guys could become “yes” guys again, if McConnell sweetens the pot for them – with less for the poor and more for the rich – but then more “moderates” might walk away from it all.

It’s a mess:

On the stump in 2016, Donald Trump told the American people that he would replace the ACA with something that protected Medicaid and offered patients better coverage with lower premiums and deductibles. And while he was more explicit than other GOP leaders in promising to deliver those things, many Republicans took advantage of Obamacare’s relatively high premiums and deductibles to suggest to voters that they favored making insurance cheaper and more robust.

Mostly, they were lying. And certainly Trump was lying.

But this was a smart thing to lie about precisely because that’s exactly what voters want from Obamacare repeal. Not draconian Medicaid cuts or for tens of millions of people to lose their insurance, but for premiums and deductibles to fall so that coverage expands and becomes more affordable.

That was always a bit odd:

This would be a very achievable goal if a dozen or so Republicans decided they wanted to work with Democrats to make it happen. A stronger mandate, guaranteed Cost-Sharing Reduction money, and a few simple tweaks like bringing back “risk corridors” and expanding reinsurance funding would set off a virtuous circle. Plans would become slightly cheaper, and going uninsured would become slightly more expensive, pushing healthier people at the margin into joining the exchanges. That, in turn, would lower average premiums and push even more healthy people into joining the exchanges which would further lower costs – lather, rinse, and repeat. The result wouldn’t be a health care utopia, but it would be an improvement over the status quo which is what people want.

But until work starts on a bipartisan deal, it’s dangerous to assume that repeal is dead.

That’s because Yglesias knows all about Republican moderates:

Relying on conservatives to kill a fundamentally conservative bill is inherently risky, and if the perception that repeal is dead demobilizes opponents then the odds of more moderate Republicans doing anything only fall. Obamacare repeal looked dead in the House at one point, but the very perception that it was dead turned out to give it new life. The only people who can really kill repeal are so-called moderates – who’d have to say no to coverage losses and yes to bipartisanship.

So far it hasn’t happened.

Yglesias is not hopeful, but Josh Marshall is:

Why did this happen? The biggest reason is that Trumpcare is supremely unpopular. The bill’s mammoth unpopularity is scarcely even questioned. Nor is there much attempt to make it more popular. Nothing for weeks has been about anything more than assembling fifty votes. Closely related to this and deepening this unpopularity is the huge and sustained nationwide activism against Trumpcare. Finally, the absolute opposition of Democrats has forced Republicans not only to push these bills solely with Republican votes but with zero bipartisan cover. The latter point is very important. Each of the three factors has reinforced the others.

But there is one deeper driver at work which makes each of the above possible. At the outset of Obamacare’s post-legislative history, Republicans were for repeal. Then repeal became ‘Repeal and Replace’, a tacit but highly significant concession that the 2009 status quo ante was not acceptable. Over time, Repeal and Replace got gussied up with claims that the replacement for Obamacare would be better than Obamacare. There was a good deal of vagueness and mendacity packaged into this messaging. But the critical thing was that in the process of evolving from ‘Repeal’ to ‘Repeal and Replace’, Republicans made a tacit concession that those who had gained coverage under Obamacare should in fact have coverage. It was just that Obamacare did it in a flawed way and Obamacare’s replacement would do it better.

These guys actually want a renamed Obamacare:

The clearest evidence is the simple fact that Republicans were so resistant to accepting the repeated Republican-appointee-led CBO scores showing tens of millions of people losing coverage. In spite of themselves Republicans had been forced to accept that the number of people covered is the core metric by which we judge any plan. Of course, most Republicans have not explicitly accepted this – but the war against the CBO scores testify to an acceptance in spite of themselves. If that wasn’t the metric, they wouldn’t care.

And then it was all over:

This de facto acceptance that those who got coverage under Obamacare should not lose coverage created a basic and largely unresolvable problem. Without an architecture at least something like Obamacare and without the taxes passed to fund it, it simply was not possible to provide coverage on this scale. There’s basically no shortcut. This has left Republicans with a contradictory set of promises that are quite hard to reconcile or fulfill.

In most respects, this is no different from what Democrats hoped would be a truism about major new programs. Once people get access to new benefits they’re really hard to take away, especially when tens of millions of people have them. Of course, none of this was foreordained and it’s far from guaranteed even now. It is quite possible that McConnell will still be able to pass a Trumpcare bill. If he does, it will immediately be passed by the House and signed into law. If that doesn’t happen it will only be because of furious and sustained activism around the country. But it is critical to understand that key difficulties Republicans are having today stem from tacit concessions about the reality of Obamacare, that now go back years.

There was no way out of that trap. They accepted, long ago, that Obamacare was a fine idea – everybody should have affordable health insurance – but said that Obamacare was flawed. But they wouldn’t fix it. They’d get rid of it – but the whole thing was still a good idea. It just turned out that there was no better idea.

Donald Trump just wanted a win – one major piece of legislation – just one, finally – not a bill that renames some damned post office. He’s not getting one. He’s having a hard time getting anything done.

About Alan

The editor is a former systems manager for a large California-based HMO, and a former senior systems manager for Northrop, Hughes-Raytheon, Computer Sciences Corporation, Perot Systems and other such organizations. One position was managing the financial and payroll systems for a large hospital chain. And somewhere in there was a two-year stint in Canada running the systems shop at a General Motors locomotive factory - in London, Ontario. That explains Canadian matters scattered through these pages. Otherwise, think large-scale HR, payroll, financial and manufacturing systems. A résumé is available if you wish. The editor has a graduate degree in Eighteenth-Century British Literature from Duke University where he was a National Woodrow Wilson Fellow, and taught English and music in upstate New York in the seventies, and then in the early eighties moved to California and left teaching. The editor currently resides in Hollywood California, a block north of the Sunset Strip.
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