This Week’s Ugly Possibilities in TrumpCare (with Things to Do)

By Lambert Strether of Corrente.

When last we checked in, the House Republicans had managed to pass a TrumpCare bill, aided by the machinations of NJ Representative Tom MacArthur, for whom Trump just raised a $800K. Being driven by the Freedom Caucus, the bill was universally panned by all other factions of both parties, and the Senate said it would write its own bill. That’s what they’re doing now, and (naturally) it’s a bad bill, too. I’ve urged that ObamaCare is already the worst possible Republican bill, but Senate Majority Leader Mitch McConnell (R-KY) seems determined to expand the range of possiblities.

Being both more feral and more concerned with results than Democrats, the Republicans, led by the wily and effective Mitch McConnell — whose wife, Elaine Chao, is head of the DOT, and therefore in the happy position of being able to dispense the goodies — may try to jam their bill through before the July recess. The American College of Physicians explains:

On behalf of the American College of Physicians (ACP), I am writing to express our great concern about reports that legislation to repeal and replace the Affordable Care Act (ACA) and radically change how Medicaid is financed is being hastily drafted and rushed forward outside of regular order for a vote on the floor of the U.S. Senate, potentially before the July 4th recess.

Specifically, we are troubled that the Senate is developing major healthcare legislation without hearings and markups by the committees of jurisdiction; without a process that allows for direct engagement and outreach to organizations representing physicians, patients and others affected by the proposed policies; and without a commitment that the Congressional Budget Office (CBO) score will be made available, with sufficient opportunity for stakeholders and the public and independent and non-partisan experts to review the CBO’s assessment and the overall bill’s impact on patients and the healthcare system, before a vote is taken. ACP therefore urges that any proposals to modify or improve on current law be released in detail beforehand—including complete legislative language and CBO scoring and analysis—well before any committee mark or Senate vote, to allow enough time for hearings on the proposals. Following regular order would provide a valuable opportunity for analysis, review and input by organizations and other stakeholders, by members of the Senate, and by independent and nonpartisan analysts.

(These process violations are, of course, in great contrast to the many careful months Obama took to sell out to the pharmaceutical companies, and for career “progressives” to suppress single payer advocacy, only, in the end, to pass a bad bill, through reconciliation, without one Republican vote anyhow.) There’s conflict on the process detail, naturally, but the ACP demands (really requests, right?) for following the regular order look quite sane to me.

There’s a lot not to like in the Senate bill — of course, we might know more if the Democrats hadn’t filled the airwaves with Putin Derangement Syndrome — but it looks to me like the key policy issue is Medicaid expansion and the key political issue is the role of those “moderate Republicans.” And here there are multiple, competing narratives. Sarah Kliff in Vox this morning:

Obamacare is in real danger

Behind closed doors, Senate Republicans have worked out a path toward Obamacare repeal. The plans under discussion would end Medicaid expansion, causing millions of low-income Americans to lose health coverage. They may allow health insurance plans to charge higher premiums to people with preexisting conditions, too.

In other words: The emerging bill looks a whole lot like the unpopular bill the House passed last month. It creates [sic] the same group of winners (high-income, healthier people) and the same group of losers (low-income, sicker people).

The Republican plan is coming together because moderate senators are beginning to drop some of their initial repeal objections. Sens. Rob Portman (R-OH) and Shelley Moore Capito (R-WV), for example, now back a plan to end the Medicaid expansion.

Both were ardent critics of the House bill’s deep Medicaid cuts, which would cause 14 million Americans who rely on the public program to lose coverage. Portman put out a harsh statement the day the House passed its health care bill.

“I’ve already made clear that I don’t support the House bill as currently constructed because I continue to have concerns that this bill does not do enough to protect Ohio’s Medicaid expansion population,” Portman said plainly.

But now Portman has endorsed a plan to phase out the Medicaid expansion entirely, just to do so on a longer timeline than the House bill. Portman and Moore Capito want a seven-year phase out, rather than the House bill’s three-year off-ramp.

At the end of the day, though, phasing out Medicaid expansion over seven years has the same effect as three years: You end coverage for millions of low-income Americans.

There are still major issues that divide Senate Republicans on repeal. There is disagreement, for example, over how much to cut the Medicaid program and what kind of subsidies to give people in the private market. But the fact that Republicans are coalescing around ending Medicaid expansion — once thought to be a major sticking point — suggests the path to repeal may be easier to find than initial expectations.

(The advantage of a seven-year phase-out is that it won’t affect 2020, so Trump’s marginal voters in the working class won’t know how badly Trump screwed those near the poverty line.) Unfortunately, given the “any stick to beat a dog” givens in 2017, I don’t feel I can simply quote Vox as a source, and the workings of the Republican caucus are opaque to me. Here’s an alternative narrative, employing 11-dimensional chess (and here let us recall that McConnell can play chess; his strategy of massive resistance to Obama put the Repubicans on the Hill where they are today). CNN:

Why Republicans might let their health care bill fail

With the Republican Party’s most pressing undertaking stuck in limbo, GOP senators and aides are beginning to wonder about one undesirable outcome: that the Senate takes a vote on a health care bill in the coming weeks knowing full well it could fail.

Republicans are attempting to use the so-called budget reconciliation process, which would allow them to avoid a Democratic filibuster. With only 52 Republicans in the Senate, however, there is no room for error as leaders struggle with the daunting task of finding consensus between their caucus’ moderate and conservative flanks on such a deeply divisive issue.

Last week, it became clear that GOP leaders were seriously considering several moderate concessions on their health care bill, including keeping some of the Obamacare taxes and not allowing states to repeal what is known as community rating — a key protection for people with pre-existing conditions.

“It might be that McConnell knows he can’t get to 50 so he’s going as far left as possible to give moderates cover when they do vote for this bill,” one conservative Senate aide said.

So why vote on a bill that may not pass?

“There’s some skepticism as to whether they can get (health care) done. And they don’t want to waste the rest of the legislative year,” said Leavitt, who served as Health and Human Services secretary under President George W. Bush.

“There has to be a moment when you say, ‘We’ve got to do something and this is the moment.’ … Either put up or stop,” he added.

If Senate Republicans bring up a bill designed to appease the more moderate members in its ranks, that strategy would mark a sharp departure from the path that House Republicans chose to take last month.

But in the Senate, GOP leaders appear more willing to craft a bill that soothes their more moderate colleagues — at least for now.

One of the key departures Senate leaders are eying is giving federal money to Medicaid expansion states for longer. Sen. Rob Portman, a Republican from Ohio, has proposed a seven-year “glide path” [controlled flight into terrain] that would more gradually phase out the federal match funds.

Another option on the table would make the [hilariously feeble] tax credits offered to help people buy insurance more generous for lower-income Americans. Those tax credits already attracted the ire of some Senate Republicans, who dismissed them as little more than “Obamacare lite.”

There has been some concern, however, that conservatives could also face another loss when it comes to those tax credits. In the House bill, Republicans were able to include language that barred the federal tax credits from being used to purchase insurance that included abortion coverage in most cases. However, under Senate rules — which only allow budgetary changes to be accepted under the reconciliation process — it’s not clear that Republicans could pass that same language.

While conservatives may not be pleased with the changes on the table, moving the bill to the left could help McConnell protect his most vulnerable members. There aren’t many endangered Republican members up in 2018, but those who are hail from more purple states, like Dean Heller in Nevada and Jeff Flake in Arizona.

Republican Sen. John Thune of South Dakota said last week that it is important for the Senate to try to pass a bill in the next few weeks, even if the vote fails.

So either McConnell is trying to jam the bill through, or, more subtly, he wants to be seen as wanting the bill, and probably does want the bill (Kentucky), unless the bill jeopardizes Senate seats in 2018. At this point, let’s remember the famous words of Karl Rove (then an anonymous source):

[W]hile you’re studying that reality — judiciously, as you will — we’ll act again, creating other new realities, which you can study too, and that’s how things will sort out. We’re history’s actors . . . and you, all of you, will be left to just study what we do.

In other words, given the time frame, it may be more important to affect reality than to game it out; by giving your Congress Critter — or, better, one of their staffers — a call. Bringing me to Indivisible, one of the Resistance organizations that sprang up (spontaneously, or not) after Trump was elected. Indivisible is said to be composed of Congressional staffers; it got good press immediately; and they have in fact prepared many useful materials to bring pressure to bear on Congress. In the great divide over what victory looks like to the Resistance — a Clintonite Restoration, or a Sanders Revolution — Indivisible comes down firmly on the side of Restoration, as this tweet from today shows:

I mean, come on. What on earth does “propose a piece of legislation that provides equal or better access to affordable, comprehensive heath care” mean? Why not health care as such, and not “access” to health care? And why not just come out and support #MedicareForAll, instead of peddling this mealy-mouthed drivel? Oh, and here’s the call script: As you can see, it doesn’t even mention proposing legislation, so the message of the tweet’s graphic, and the message of the actual script contradict each other (hopefully due to carelessness rather than bad faith. Some process).

That said, Indivisible does do good work aggregating establishment pressure points; here is their list of Congressional staffers who work on health care. They write:

the person answering the phone when you call your member of Congress’ office will be a staff assistant or intern. You should always ask for the Senator’s legislative assistant who handles that particular issue for the Senator. In this case: health care. Often times, you’ll be put through to that person’s voicemail. Leave one. And then use the information below to send a follow-up email.

I agree with the tactic, and plan to call my two Senators — Moderate Republican Susan Collins, and Independent Angus King — this afternoon. You should consider doing the same. I write my own scripts, but there’s no reason you can’t use or adapt theirs. However, I plan to add verbiage like this:

Of course, the real solution isn’t this Republican plan, or ObamaCare (which originated at the Heritage Foundation). The real solution is Medicare for All. We know from the Canadian experience that single payer saves tens of thousands of lives and will save the country billions of dollars. Medicare for All is something even limited government should so, and I hope one day you will support it.

Can readers improve on this?

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About Lambert Strether

Readers, I have had a correspondent characterize my views as realistic cynical. Let me briefly explain them. I believe in universal programs that provide concrete material benefits, especially to the working class. Medicare for All is the prime example, but tuition-free college and a Post Office Bank also fall under this heading. So do a Jobs Guarantee and a Debt Jubilee. Clearly, neither liberal Democrats nor conservative Republicans can deliver on such programs, because the two are different flavors of neoliberalism (“Because markets”). I don’t much care about the “ism” that delivers the benefits, although whichever one does have to put common humanity first, as opposed to markets. Could be a second FDR saving capitalism, democratic socialism leashing and collaring it, or communism razing it. I don’t much care, as long as the benefits are delivered. To me, the key issue — and this is why Medicare for All is always first with me — is the tens of thousands of excess “deaths from despair,” as described by the Case-Deaton study, and other recent studies. That enormous body count makes Medicare for All, at the very least, a moral and strategic imperative. And that level of suffering and organic damage makes the concerns of identity politics — even the worthy fight to help the refugees Bush, Obama, and Clinton’s wars created — bright shiny objects by comparison. Hence my frustration with the news flow — currently in my view the swirling intersection of two, separate Shock Doctrine campaigns, one by the Administration, and the other by out-of-power liberals and their allies in the State and in the press — a news flow that constantly forces me to focus on matters that I regard as of secondary importance to the excess deaths. What kind of political economy is it that halts or even reverses the increases in life expectancy that civilized societies have achieved? I am also very hopeful that the continuing destruction of both party establishments will open the space for voices supporting programs similar to those I have listed; let’s call such voices “the left.” Volatility creates opportunity, especially if the Democrat establishment, which puts markets first and opposes all such programs, isn’t allowed to get back into the saddle. Eyes on the prize! I love the tactical level, and secretly love even the horse race, since I’ve been blogging about it daily for fourteen years, but everything I write has this perspective at the back of it.


  1. craazyboy

    I think in this case, where there really is only one effective long term solution which can be implemented in the short term, but we have 500 lawmakers so intent on maintaining fiction, that I’ll give straight Brownian Motion odds on the bill passing , or not.

    It’s a cornucopia of excuses that can be quickly spun any direction by the players immediately post vote. As an aside, I love our current (and only) vote stratagem used by Congress fauna. If you like the bill, full of really crappy stuff that will get you unelectable, vote against it. It will make your voting record look good!

    All sorts of the usual 11 dimensional chess and false flag spin doctoring fodder.

    I like this one – Attack Medicaid in OCare. Here it’s pre-spun (Knuckle Ball?) as it’s being eliminated for 14 million Americans.

    Demographic Target:

    1) Top 80% – Win! ‘Cause we all know monopoly supply and demand rules are in force. TPTB just know prices are prices, and true costs are sumthin’ different. (mostly hidden profits)

    2) Top 50% – Win! With reservations. Safety programs cuts are disturbing. May need someday, or likely to have a needy relative!

    3) Bottom 30% – Lose initially, but damage control. Post vote, point out the Medicare is being pushed down to state level, for more personalized attention.

    (Mentholated tentacle balm for those free procto exams by overly friendly and chatty robots. No lines! Made in China. Robot also hums while he/she works. Free because – Inclusive!)

    Concern Trolls (unknown quantity – but we all are in public. hahaha.)

    Very supportive because, “The States can do it better and cheaper!”

    That’s without thinking about it too much. The MSM and focus groups will have much more to add.

    1. craazyboy

      oops. typo.

      Post vote, point out the Medicare is being pushed down to state level,

      Medicare s/b Medicaid. AFAIK, Medicare reform is still TBD.

  2. marym

    Suggestion for those of us with Democrat Senators: Call to let their health care legislative assistants know we expect the Senators to use all Senate procedures and all their ability to access the media to fight the Republican plan keep the public informed. Adding Lambert’s verbiage on Medicare for All if that’s also something one supports.

  3. Carla

    I think it’s too late.

    Should some calamity bring about Medicare for All in the near term, it will NOT be expanded and improved. It will be crapified beyond recognition, and the single payer will be UnitedHealth Group, Anthem or Aetna — because obviously, government can’t do anything, nor will it be allowed to. UnitedHealth, under the name Optum, is already privatizing the National Health Service in the UK.

    Until we establish that only human beings are entitled to constitutional rights, and money is not speech, the global corporate blob is not going to permit the nationalization of ANYTHING. My God, they’ve privatized a huge chunk of the military and the “intelligence” services.

    So check out

    See if your Congess Critter has co-sponsored, then get on the phone to either urge or thank. And call your Senator to ask it (okay, tell it) to introduce companion legislation in the Senate.

    1. PH

      I agree.

      Corporations are creations of statute (there was no common law right to make a corporation).

      Not only are corporations not entitled to the status of persons under the Constitution (no matter what the sct said), the statutory rights should be drastically curtailed.

      First, make a Federal statute, and preempt all state law. Under Federal statute, do not permit any corporation to own the shares of any other corporation. Allow only one class of stock. Require public disclosure of all sharehoders. And require public filing of financials each year.

      That and public banks would make a much more transparent economy and tax system.

      Public concerns

      1. Carla

        Yes. And we can’t re-claim the ability to act on behalf of the public until we abolish corporate personhood and ditch the lie that money = speech. Until then, public banks could not really be public at all. Nor can we have expanded, improved Medicare for All — single payer — worthy of the name.

        Charter corporations for specific purposes and limited periods of time, 20 years for example. If they stray from their stated purpose, you pull the charter. All of this was common under state law in the 19th century. Corporations were not allowed to be immortal. If their purpose requires staying in business for more than two decades, let them make the case to get their charter renewed.

        1. PH

          Early 19th century corps were for public purpose — justifying limited liability. Build a bridge. A turnpike. Maybe a canal (not sure).

          Banks were viewed in that vein.

          Most business remained sole proprietor or partnership till 1870? Later?

          Better credit analysis if you knew the person you were lending to.

          Not sure iwould insist on time limit. But i would insist on public disclosures.

    2. roxan

      Ugh! United Health is the worst insurance company I ever dealt with. They would not even tell me what they covered. Nasty, nasty, nasty….

    3. lambert strether

      > I think it’s too late.

      With single payer making good headway in NY and CA and with more national prominence than ever before? I disagree vehemently.

      1. Carla

        Do you consider “single payer” with UnitedHealth as the single payer to be an improvement? Can you see a way for “single payer” to be a public-private partnership?

        Medicare has never covered more than 80 percent of medical bills, and has been very significantly privatized with Medicare Advantage.

        When does Medicare for All become just another empty sound-bite, like Trump’s PPP Infrastructure scam?

  4. cripes

    If the POS democrats spent more time screaming about health care, medicare, medicaid, meals-on-wheels, HUD housing, food stamps, all poised to be decimated by the POS republicans, instead of blaring Trump-Putin all day, every day through the POS media, then maybe I’d piss on them if they were dying of thirst.

    But, no. They’re doing everything possible to provide cover for the POS republicans who are working diligently to shred public services and privatize the remaining parts. Just to raise their miserable chances of re-election a couple points. And looting.

    And they’ve got the perfect foil, bad-guy, fall-guy, the perfect excuse in the dummy, Trump. Endless phony scandals, blowing smoke up the collective national ass, while the looting and bombing continue unabated, nay, multiply like flies on a carcass.

    Pharma lobbyists, TV ad buys and two-dollar hookers posing as politicians crushed single payer in Vermont and Colorado.

    A single victory in New York or California could break open the damn. And the energy release of that victory, the fear of the people in the halls of corruption, oh man, the possibilities.

    I pray for armies of volunteers from every state, led by nurses and doctors, fueled by dollars, mass demonstrations and credible threats to end the career of any state legislator who dares to stand in the way.

    All it took for Canada was little ol’ Saskatchewan.
    WTF are we waiting for?

  5. allan

    On this (Tuesday) morning’s front page of the online Washington Post,
    there is not a single mention of the AHCA.

  6. teri

    Coming up for a vote soon is a bill that is separate from the Trumpcare bill:
    Verify Eligibility for Health Care Tax Credits – HR2581

    The descriptor: “The bill would modify both current law and the American Health Care Act to prohibit the advance payment of health care premium tax credits to individuals unless the Treasury Department receives confirmation from the Health and Human Services or Homeland Securities departments that they have verified the individual’s status as a U.S. citizen or lawfully present alien.”

    Health care premium tax credit means a tax credit you can take in advance to lower your monthly health insurance payment (or “premium”). When you apply for coverage in the Health Insurance Marketplace, you estimate your expected income for the year. If you qualify for a premium tax credit based on your estimate, you can use any amount of the credit in advance to lower your premium.  In other words, these are the subsidies available on the exchanges to lower your premiums to what you can afford (the gov’t kicks in some money, based on your need, to pay the rest of your monthly premium to the insurance company).  This is the bedrock of Obamacare.

    This bill, separate from the Trumpcare bill, appears to mean that whether Congress puts Trumpcare in place, or keeps Obamacare, here’s what happens when you apply for whatever subsidies under either plan are still available:  your application for subsidy is delayed while Homeland Security or the HHS check into your citizenship and notify the Treasury that you are good to go. While you are waiting for this verification, which will take God knows how long, one can only assume you are responsible for the entire monthly insurance premium, which you can’t afford, or you wouldn’t be looking for a subsidy in the first place.  The insurance company and your state are likewise left wondering about your ability to pay. For your state, this means they are left uncertain as to how much they will be kicking in on your behalf, and for the insurance company, they are left wondering if they are going to be paid at all, and if so, how much.

    Another way to get the insurance companies to bail out of the exchanges, whether or not they pass Trumpcare.  [Note that the bill, if passed, applies to either Obamacare or Trumpcare.]

    Enough.  We need universal healthcare!

    1. marym

      Maybe the Republicans will make it so impossible for anyone to afford private insurance or to qualify for privatized Medicaid that the insurance companies will go out of business. Is that our only chance for universal publicly funded health care?

      1. Carla

        No. The banks will take over where the insurance companies left off — IF WE LET THEM.

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