Did The Far Right Render Ryan's Health Care Repeal Dead On Arrival?

A brand new Monmouth poll, found that 51% of Americans said they would prefer to keep the Affordable Care Act and work to improve it, with another 7% saying they want to keep the ACA entirely intact. That's 58%, while only 39% want to see the ACA repealed, either with a replacement (31%) or repealed entirely without a replacement, the Freedom Caucus' preferred outcome (8%). Just as that poll was being released yesterday, Mike Lee (R-UT) was at odds with the House Republican leadership's talking points, pointing out that Ryan's bill "is exactly the type of backroom dealing and rushed process that we criticized Democrats for." And House Freedom Caucus crackpot Mo Brooks (AL), for example, said that Ryan's Obamacare replacement "is a huge step in favor of socialized medicine" and that he'll vote against it and will only back total repeal. But not every member of Congress hates the Ryan ACA repeal plan. Utah's most odious and pathetic Establishment lapdog, Jason Chaffetz, was out regurgitating the GOP leadership's mostly deceitful, focus-group-tested talking points on early morning TV Tuesday:

• we campaigned on this
• death spiral
• premiums are going up, I think 25%
• Arizona, 100%
• deductibles up/choice down
• almost one third of the counties in this country have only one choice
• access, access, access...
• we've got to save health care for the American people

As you can see on the soon-to-be-classic segment above, when confronted with the facts from the Kaiser Foundation-- "with Medicaid reductions and smaller tax credits, this bill would clearly result in fewer people insured than under the ACA. The House GOP proposal seeks to reduce what the federal govern,went spends on health"-- Chaffetz extolled choices like this: "rather than getting that new iPhone that they just love, that they want to go spend hundreds of dollars on, maybe they should invest it in their own healthcare. They've got to make those decisions themselves." No, really; he said that. I swear. Watch for yourself; it's a short video.

Cadavers don’t need health insurance

Vulnerable Chicagoland GOP Rep. Peter Roskam was laying low-- and continuing to avoid his constituents, while Democratic opponent and health care advocate Geoff Petzel was talking with voters about health care-- while the Chicago Tribune thundered that the Ryan repeal plan is even worse than anyone expected, not exactly what Roskam wanted to hear yesterday. Michael Hiltzik's verdict: "it’s a nastier, more consumer-unfriendly proposal than even close followers could have expected." He summed up exactly what Chaffetz and others like him have been out on the stump doing:

The House GOP, in a written statement, cloaked this plan with a bodyguard of outright deceit. “What we’re proposing will deliver the control and choice individuals and families need to access healthcare that’s right for them,” the statement said. House Speaker Paul D. Ryan (R-WI) said the measure would “drive down costs, encourage competition and give every American access to quality, affordable health insurance.” Curiously, the GOP statement says the plan embodies “President Trump's proposed healthcare reforms,” although the president has never advanced a coherent set of proposals.

The truth is that the GOP measure would destroy the ability of millions of Americans to access any healthcare worth the name. The Congressional Budget Office reportedly warned the Republicans that their proposals would lead to lost coverage for millions and higher costs for millions more, but the GOP is pushing ahead anyway.

...The proposal defunds Planned Parenthood. No federal funding can be made, either directly or indirectly, by Medicaid to a healthcare organization that “provides for abortions,” other than those done in cases of rape or incest or to save the life of the mother. That’s Planned Parenthood. It’s proper to note that Planned Parenthood doesn’t use federal funds to pay for abortions, as that’s already against the law. This measure shuts down funding for the organization just because it uses other funds to cover those procedures.

The bill effectively shuts down private health insurance coverage for abortion. According to a House Ways and Means Committee digest, the measure forbids spending federal tax subsidies on health plans that include coverage of abortion, even if the customer doesn’t get an abortion. This would dramatically shrink working Americans’ access to insurance-covered abortions, or would lead to insurers dropping abortion coverage from their plans, or both. Customers could buy separate policies to cover abortions, but couldn’t use the federal subsidy to help pay for them. Insurers likely would charge hugely discouraging premiums for such policies, as the market for them would be tiny.

The individual and employer mandates are eliminated. They’re not repealed exactly, but the penalties are repealed, which amounts to the same thing. Without a requirement that individuals carry health insurance, the insurance markets are almost certain to collapse. The repeal is retroactive back to the beginning of 2016, but the real problem is in the market starting this year. Individuals would be able to drop their coverage immediately, which will wreak havoc with the market starting right now. Aetna’s chairman and chief executive, Mark Bertolini, said recently that the individual market was entering a “death spiral” in which healthier customers dropped coverage, leaving sicker customers who know they need insurance facing an ever-increasing rates. This provision will do much to guarantee that will happen.

Essential health benefit rules are repealed. As of Dec. 31, 2019, ACA rules that required qualified health plans to provide hospitalization, maternity care, mental health services and other benefits would be sunsetted at the federal level. States would have the authority to set them instead. The impact on private, non-Medicaid plans would therefore vary by state. If a state removes maternity benefits, for example, that’s likely to make maternity coverage, among other services, immensely expensive, if available at all.

Income-based premium subsidies would be replaced by age-based subsidies, which will hurt working-class families in many states. Under the ACA, subsidies to help individual buyers afford premiums and (for poorer households) deductibles and co-pays were based on household income. The GOP measure will base them on the buyer’s age, instead, with older buyers receiving more help than younger. The GOP plan limits subsidies to $4,000 per individual; under the ACA, which also keys subsidies to the cost of benchmark insurance plans in the buyer’s home market, the subsidies theoretically could be several times higher. No family could receive more than $14,000 in subsidies, and no more than five family members could be eligible for subsidies.

As we reported last week, this scheme would reduce subsidies to many of the people who need them the most, while awarding them to recipients who don’t need them. “People who are lower income, older or live in high-premium areas would be particularly disadvantaged,” the Kaiser Family Foundation observed after examining an earlier draft. The new draft retains those features. Some modest means-testing of the subsidies-- an idea tossed around within the GOP caucus last week to quell complaints that the change would make the rich richer-- appears to be incorporated into the fiscal provisions of the proposal.

The Medicaid expansion is killed. As of Dec. 31, 2019, the Medicaid expansion is repealed. Traditional Medicaid will be block-granted, a system almost certain to result in less federal funding for the joint state-federal program than it would have received, over time. The neediest and sickest Americans will increasingly be on their own, as states get less federal help to provide them with medical services.

All of Obamacare’s taxes are repealed, another boon for the rich. Everything from the tax on tanning salons and medical devices to the surcharge on high-income taxpayers will be gone. As we explained earlier, this amounts to an enormous tax cut for the wealthy-- at least $346 billion over 10 years, every cent going to taxpayers earning more than $200,000 ($250,000 for couples). The proposal would sharply raise the limits on contributions to tax-advantaged Health Savings Accounts-- another gimme for the rich.

The tax repeal, the Brookings Institution has reported, will make it impossible to pay for any Obamacare “replacement”-- which still isn’t on the horizon. It also will exacerbate the fiscal problems of Medicare, by hastening the exhaustion of the program’s trust fund by four years, to 2025.

Not only would the Ryan plan give huge tax cuts to the wealthiest Americans and to drug, insurance and medical-device companies-- and even give a special tax break for health insurance CEOs-- it hikes premiums by 30% for people with pre-existing conditions if for any reason-- such as losing a job-- they don’t have coverage for 63 days. That's what Hiltzik must have had in mind when he wrote it's "a nastier [and] consumer-unfriendly." So... no, Democrats are not getting behind this monstrous and destructive mishmash. But neither are many Republicans. The Democrats only need 3 Senate Republicans to kill it and there are already 6 who have said they don't like it-- for various reasons-- enough to vote for it. On top of that, House anti-healthcare extremists on the far right fringe, are going crazy and denouncing it like mad. The week, the Conservative Review was fuming that the Ryan plan was based on an "entire premise of GOP lobbyist-driven negotiations over Obamacare are about as divorced from the reality of free markets as our thoughts are from the thoughts of God," concluding that House Republicans "continue to accept the entire premise of the RINO-care framework, and are merely negotiating the fine print. They are insufferable." 

Their analysis may be all wrong from top to bottom, but for right-wingers who buy into it, there's no way to back Ryan's bill. They've deluded themselves into thinking Señor Trumpanzee will ride to the rescue. "Trump needs to give a landmark speech laying out a vision of free market health care. As a populist with the persona of 'America’s entrepreneur,' he is the perfect messenger to rail against the Big Government/Big Pharma cartel working to stifle innovation and competition in the hopes of preserving the troughs for more subsidies. Trump needs to ask the American people and Congress if they want a health care system that looks more like Walmart and Uber or one that looks like the Post Office, the DMV, and a mini bar in your hotel room. Trump must call all the CEOs of health insurance companies into his office and tell them loudly and clearly: “we will not regulate you, but we will not subsidize you either. The era of government-run health care is over. Go out and compete for business.” He should also promise them that once full repeal is signed, he will promote cross-state line insurance, equal taxation for the individual market, and repeal of even pre-Obamacare interventions and regulations. This will ensure a healthy and robust individual market that is worth competing in." WOW! Talk about delusional The completely out-of-his-depth Trumpanzee-in-chief already tweeted that he loves the bill.

Heritage Action, which is never reluctant to crack a whip over the heads of Republicans headed in even a slightly a mainstreamish direction, was fuming by Tuesday morning. Their perspective is that the bill "not only accepts the flawed progressive premises of Obamacare but expands upon them... bad politics and, more importantly, bad policy... [Republicans] should fully repeal the failed law and deliver on promises that create a free market health care system."

By late Tuesday, even the Trumpanzee Daily News Breitbart website was denouncing Ryan's replacement proposal in no uncertain terms. "The Obamacare 2.0 bill," wrote one of the staff neo-Nazis, "pushed by some Republicans strips out even Obamacare’s weak protections preventing illegal aliens from signing up for health care meant for citizens." She then made a paranoid wing-nut case about how Ryan has put together a bill that will flood America with Hispanics obtaining counterfeit drivers licenses or something like that.

Justin Amash (R-MI), on the other hand tweeted within minutes of Ryan declassifying the plan that it's "Obamacare 2.0." Tuesday morning Rachael Bade laid out congressional wing-nut opposition for Politico readers, starting with extremist kook and Freedom Caucus chairman Jim Jordan (R-OH) saying that the Ryan plan is "Obamacare by a different form." His members "dismissed the bill as creating a new 'entitlement program' by offering health care tax credits to low-income Americans." The all-powerful House Republican Study Committee memo sent to chiefs of staff echoed those comments and blasted the bill’s continuation of the Medicaid expansion for three years.

Freedom Caucus member Dave Brat (R-Va.) piled on, telling Politico he’d vote against it in its current form because “the bill maintains many of the federal features including a new entitlement program as well as most of the insurance regulations.”

"Now [they] are saying we're going to do repeal and replace but the bill does nothing of the sort,” he said. “[Speaker] Paul Ryan has always said the entire rationale for this bill is to bend the cost curve down, and so far I have seen no evidence that this bill will bring the cost curve down.”

...“This is a Republican welfare entitlement,” the RSC memo reads. “Writing checks to individuals to purchase insurance is, in principle, Obamacare. It does allow more choices for individuals, and is more patient-centered, but is fundamentally grounded on the idea that the federal government should fund insurance purchases.”

It is unclear if conservatives who still don’t like the bill would be willing to vote against it, potentially blocking the repeal effort from passage. While Brat said he’d vote against it, few others have taken a position yet. House Republican leaders expect some conservatives and moderates to oppose the measure on the floor. But they can only afford to lose 21 votes.

RSC chairman Mark Walker in a statement thanked leadership for their work on it and said “I applaud the movement and believe it is the right direction.”

“We are carefully reviewing this legislation looking in three main areas of shared conservative concern: protection of the unborn, elimination of Obamacare’s Medicaid expansion and ensuring the tax credits are fiscally responsible,” the North Carolina Republican said.

The RSC's steering committee will meet Tuesday to discuss next steps forward.

Freedom Caucus members, meanwhile, talked amongst themselves about the bill. While many believed the final version was more to their liking than older drafts, one source wasn’t sure if conservatives could get on board with GOP’s plan to offer advanceable, refundable tax credits. Such credits are a key pillar of the Ryan plan and one of the most controversial issues for conservatives. They worry the plan will create an entitlement and have been pushing for a tax deduction instead.

The attraction-- and temptation-- for many nervous Republicans, of course, is that it reduces taxes on the very rich, the people who have financed their careers. As Richard Rubin explained for Wall Street Journal readers Tuesday, "Households at the top of the U.S. income ladder would see taxes on their wages and investments drop under the House Republicans’ new health-care proposal, a repeal of a 3.8% tax on investment income and a 0.9% tax of wages for only the highest earning Americans.

The other day the American Hospital Association rejected Ryan's replacement bill (TrumpCare) and this morning the much more politically powerful American Medical Association did the same. From the AMA:

The American Health Care Act (AHCA), released by Congress this week, is intended to repeal and replace the Affordable Care Act (ACA). But as introduced, it does not align with the health reform objectives that the AMA set forth in January to protect patients. While the ACA is imperfect, the current version of the AHCA is not legislation we can support.

The replacement bill, as written, would reverse the coverage gains achieved under the ACA, causing many Americans to lose the health care coverage they have come to depend upon.

...It is unclear the exact impact this bill will have on the number of insured Americans, and review by the nonpartisan Congressional Budget Office is still pending. The ratings and analytics firm S&P Global Ratings has already estimated that as many as 10 million Americans could lose coverage if this bill becomes law, saying that between 2 million and 4 million people could lose the insurance they purchased in the individual health exchanges under the ACA, and between 4 million and 6 million could lose their coverage under Medicaid.

That just won’t do.

We all know that our health system is highly complex, but our core commitment to the patients most in need should be straightforward. As the AMA has previously stated, members of Congress must to keep top of mind the potentially life-altering impact their policy decisions will have.

We physicians often see patients at their most vulnerable, from the first time they set eyes on a newborn child to the last time they squeeze a dying loved one’s hand. We don’t want to see any of our patients, now insured, exposed to the financial and medical uncertainties that would come with losing that coverage.

We're going to continue this discussion in the next post, when you'll meet a Democratic candidate running for Congress from Houston, a doctor-- cancer specialist Jason Westin-- who is challenging entrenched, but now vulnerable, Republican troglodyte John Culberson.