HEJE Overview 7-25-17: Healthcare

QOTD

What are senators voting on exactly?  –Er, they’ll get back to you.

Update: They got back to us, but we’re still confused.

  • AHCA/BCRA (or whatever): Will it or won’t it (proceed), that is the question

So:  we know that 50 R’s have to vote for whatever-it-is-that-comes-up-today in order to proceed to a discussion; Senator Collins is a “no”, and there are questions about Senators Paul, and possibly, Capito, Murkowski, Heller, Portman, Lee, and Moran –so, quite a list.

Update: They voted to proceed, 50-50 with the VP casting the tie-breaking vote. Later, on Tuesday night at the first vote, the following Republicans voted against the BCRA (which included amendments by Ted Cruz and Rob Portman): GOP Sens. Susan Collins (Maine), Bob Corker (Tenn.), Tom Cotton (Ark.), Lindsey Graham (S.C.), Dean Heller (Nev.), Mike Lee (Utah), Jerry Moran (Kan.), Lisa Murkowski (Alaska) and Rand Paul (Ky.).

So, BCRA down (43-57). Next up: Repeal, apparently. That should go over well.

  • The options in the “vote-a-rama” that will continue until Friday

The Senate voted to proceed to discussion of repeal and replace on Tuesday evening, but it looks like they’ll have to try out various iterations—including a straight “repeal” vote and a minimal, stripped-down just-barely-changed version—as votes continue until Friday. Some of the features that will be introduced won’t have been scored by the CBO; others are almost surely doomed to fail outright.

“Senate Republicans will at some point also have to vote on a delayed-repeal bill modeled on 2015 legislation that then-President Obama vetoed. Ironically, if the legislation became law, premiums would skyrocket, insurers would leave the exchanges and 32 million fewer people will have coverage by the end of the decade.”

  • Additional details on how the voting will likely proceed

The vote on the motion to proceed was 50-50, with the VP breaking the tie. The first vote, on the more-or-less original version of repeal-and-replace (with new amendments including those of Ted Cruz and Rob Portman), failed, 43-57.

Next up: the repeal bill, which will be put to a vote on Wednesday. This too is considered likely to fail, not least because it would lead to a loss of insurance for more than 30 million people.

“Allowing a vote on straight repeal was necessary in order to get legislation to the floor. Conservative hardliners like Sens. Rand Paul (R-Ky.) and Mike Lee (R-Utah) can then tell voters they followed through on campaign promises to dismantle the Affordable Care Act. It will also give conservative advocacy groups, which are still crusading for repeal, a chance to hold senators who fail to back the bill accountable. They’re likely to seek primary challengers to some of the senators who fail to back straight repeal. They’ve already begun attacking Sens. Lisa Murkowski (R-Alaska) and Shelley Moore Capito (R-W.Va.) as hypocrites for failing to follow through on campaign promises.”

After 20 hours of debate, the Senate will proceed to a series of voting rounds (probably on Thursday) at which amendments—including amendments by Democrats aimed at improving/stabilizing the ACA—will be voted on and successively discarded as they fail.

Also worth keeping in mind: the Senate Parliamentarian has deemed that a number of features of the bill go beyond budget reconciliation and involve actual shifts in policy. These will need 60 votes to pass—which isn’t going to happen.

On Friday, what the Senate may end up doing—and this, solely to have something to pass back to the House so that discussion can continue—is voting a “skinny” version of the bill which will do away with individual and employer mandates and the medical device tax.

Even these would be sufficient to bring the ACA down—which, after all, appears to have been the point all along.

  • Come what may, the ACA is toast

What the Senate votes on “could be previously passed legislation repealing but not replacing big parts of the ACA (which President Obama vetoed). Or it could be some iteration of the Better Care Reconciliation Act, the measure McConnell wrote behind closed doors and has amended several times in hopes of gaining the 50 votes needed to pass it.”

The President wavers about who’s to blame for the Republicans’ inability to repeal and replace the ACA: one day it’s the R’s (“Any senator who votes against starting debate is telling America that you are fine with the Obamacare nightmare, which is what it is”), while just a few days previously (six, to be exact), it was the D’s (“We’re not going to own it. I’m not going to own it. I can tell you the Republicans are not going to own it. We’ll let Obamacare fail and then the Democrats are going to come to us”).

“Trump promised both a guarantee of health care for everyone as well as lower health insurance premiums, more choice in doctors and reduced out-of-pocket costs.” [emphasis added]

Perhaps his advisors forget to explain to POTUS that there’s only one system that delivers those three benefits—and it’s not called AHCA or BCRA.

Message to POTUS: When your first piece of signature legislation fails, you own it. Rather like the broken vase in the china shop, actually.

  • Dean Baker says what some people have been thinking

Even if none of the various versions of the repeal and replace bill eventually pass, the ACA is going down. Baker: “The idea appears to let the health care exchanges, which are the centerpiece of the ACA, fall apart as more insurers leave.” This, despite the fact that the “assessment of the Congressional Budget Office, the Kaiser Family Foundation and others is that the health care exchanges had largely stabilized and insurers were now able operate profitably.”

Of course, there are now 1,300 counties in the U.S. with only one insurer, and some have none. “That is indeed bad news, but the lack of competition in the exchanges is overwhelming a problem for people who live in states controlled by Republicans. While more than 20 percent of the people who live in states with Republican governors only have one insurer in their exchange, this is the case for less than 2 percent of the people who live in states with Democratic governors.”

The means by which the exchanges could be undermined beyond repair include: (1) ceasing to pay reimbursements to help make insurance more affordable for the poor; (2) refusing to enforce the individual mandate, “a sure path to a death spiral. In this scenario, insurers raise rates because of their less healthy pool. The higher rates discourage healthier people from getting insurance, further worsening the health of the average insure. This cycle will continue until the pool only includes the least healthy and most expensive patients.”

Update: It looks like the final, “skinny” version of the bill will in fact do just this: do away with both the individual and employer mandates.

  • President appears uncertain about meaning of “health insurance”

“The problem appears to be that Trump himself has no idea what he is trying to do. Now he’s urging Congress to repeal the ACA as if the events of the past week did not even happen. Presidents can be effective without deep knowledge, but not bothering to figure out what Congress is voting on is really pushing it.”

“Trump refuses to delegate tasks to competent people or to learn more about the issues so he can engage with them directly. That is his choice.”

  • More opioid-addicted babies born in Cherokee Nation

“Almost 90 million opioid pills were dispensed in the 14 Oklahoma counties that make up the Cherokee Nation’s land last year, which means about 96 pills were sold for each adult… The new figures and details were disclosed in court papers filed by the Cherokee Nation as part of its lawsuit that accuses six companies, including Walmart and Walgreens, of boosting profits by illegally flooding Indian Country with prescription opioids … [it] is one of at least 25 suits filed in the past year by local governments against the companies that make up the $13 billion-a-year opioid industry.”

Inevitably, an increasing number of infants are born addicted to opioids, and must be placed on morphine drips to avoid the most acute symptoms of withdrawal. “… suffer developmental and cognitive problems and are more likely to have health and behavioral problems when they begin school.”

Defendants (the companies) are arguing that the case does not belong in Cherokee Nation District Court, where it has been filed.

  • The Charlie Gard case, discussed by a physician

The Charlie Gard case was not an instance of “death panels,” but one where physicians and parents of a child born with a rare fatal genetic disorder disagreed on the course of care. As Adam Gaffney points out, cases like this occur often, but where there is agreement between physicians and parents, they do not garner public scrutiny. This case  is a personal tragedy for the infant and his parents, but it does not symbolize the failure of Great Britain’s NHS.

Deedspeakout: the issue here is different, but involves something neither side wants to discuss—the one side out of respect for the grieving parents, the other out of hypocrisy: how much were the little boy’s parents billed for his care throughout the first 11 months of his life in England? How much would they have been billed in the U.S.?

Illinois Update: Heading for a showdown at the not-OK statehouse corral

As just about every sentient Illinoisan foresaw, it’s a duel-to-the-death in Illinois over SB1, the evidence-based funding bill for K-12 schools. The governor has called the legislature back into session as of Wednesday, but nobody (a) knows what’s in his purported Amendatory Veto; (b) knows which version of the bill will be forwarded to him for vetoing; (c) knows whether he’ll meet with the GA leadership (we predict no; the new COS, Ms. Rasmussen, who arrived courtesy of the IPI a couple of weeks ago, is rumored not to enjoy cordial relations with the Democratic House Speaker); (d) understands what the governor’s ultimate objective(s) is (are); (e) understands what the Speaker’s ultimate objective(s) is (are), and so on ad infinitum.

The governor, in our view, is playing it anti-statesmanship all the way by telling voters downstate that the Chicago Public School system is getting a “bailout” from hard-pressed taxpayers, and that the $100 million (or $200, or $250—nobody understands where the numbers are coming from) that he doesn’t want to go to CPS will be re-distributed to downstate school districts.

Note: Playing off Chicago against downstate on school funding is not exactly a 21st-century political win. What the state needs is someone who will do the opposite. And it suggests to us that somebody from out of state is adopting some pretty old and trite ploys to defeat SB1–they really need to update this playbook.

We think more is going on here than even this already-Byzantine series of machinations between a ticked-off governor and his rival, an old-school Chicago machine politician. Rich Miller recently pointed out that an organization called Stand for Children has been heavily involved in the SB1 process and contributed generously to pro-SB1 Democratic statehouse campaigns in 2016 to guarantee a Democratic legislature in the state.

Anybody who’s been following the pro-charter-voucher-cyber-homeschooling movement in the U.S. generally can see what’s happening behind the scenes: there’s a battle going on for control of education policy in Illinois, which recently received very poor marks on its ALEC “Report Card”. Rauner is the front-man and is no longer calling the shots: the IPI and ALEC are–and you can bet there’s a ton of consultancy money flowing all over Springfield and Chicago to ensure that SB1 goes down in flames.

One man is standing between Illinois’s past and future as an ALEC-controlled state, starting from education: Michael J. Madigan.

Illinois politics–like politics everywhere–is chock-a-block with ultimate ironies, and this has to be one of recent history’s finest.

This is a rapidly-(d)evolving crisis, and we’ll provide updates as often as possible. In the meantime, readers can consult capitolfax and Illinois Playbook at Politico for hour-by-hour developments.

 

 

 

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