Ultimatums Usually Work, Except When They Don’t
The Trump Administration’s first really big political test is underway today.
Frustrated with intra-partisan wrangling about the terms of the American Health Care Act, President Trump said yesterday that he was “done negotiating” on the terms of the proposal to “repeal and replace Obamacare” bill. Both he and Speaker Paul Ryan have staked a great deal of political capital on the passage of this bill out of the House.
Democrats are dead-set against it, so the bill will require passage with basically only Republican votes. That means Republicans can afford no more than 22 “nay” votes from their side of the aisle. And as of the time I’m posting this squib post, current whip counts show about 30 “nays” from the GOP caucus and an unusual set of floor defections on the rule for debate. Most of this dissent seems to be coming from the Freedom Caucus, whose members have taken the position that the AHCA doesn’t do enough to reverse Obamacare policies. But for every change to accommodate the Freedom Caucus’ desires, more moderate Republicans from more marginal districts face pressure to vote no because such a bill will do too much to reverse Obamacare policies.
None of this addresses the problem that passage of something like the AHCA out of the Senate looks well nigh impossible, for similar reasons as the House confronts — plus the Senate’s filibuster rule. Nor does it get to the issue of what would happen in the bicameral conference that inevitably would result from the Senate theoretically passing a different bill on the same subject.
A floor vote on the House of Representatives is scheduled to happen at some point between 4:00 and 5:00 p.m. eastern time today. House Republicans have no plan “B.” As I see it, it’s a huge hit on both Trump’s legislative strength and Ryan’s Speakership if the bill doesn’t pass: both put huge weight in the campaign on the Republican party’s promise to repeal and replace Obamacare.
I haven’t bothered to call my Congressman about this issue because my Congressman is Kevin McCarthy. He’s kind of committed to voting “yes” since he’s the House Majority Leader. Maybe your representative is a bit more persuadable than mine.
Maybe I’m pretty sure that some of you have some thoughts on this pending event. So, discuss! Consider this a mostly-open thread focused on U.S. politics generally, but with special emphasis on the political issues surrounding the ACHA.
Image by elbragon 
CNN is reporting, via a GOP source, that Ryan just informed Trump they don’t have the votes to pass it.
I expect the arm-twisting to continue but….this was never a circle they could square, and that was before those 17% approval numbers on the bill started floating out.
“Spend less money, don’t spend any money at all, make sure nobody loses insurance or that it costs more, get government out entirely, don’t upset my constituents….”
The ACA was the best “conservative” solution to healthcare in the US. There was plenty of fiddling to the core idea you could do, but regulated private insurance with mandates was the most free-market, GOP-ideology friendly solution.
It’s not sufficiently conservative for quite a number of Republican politicians, which means any solution will have worse results. Which is fine, except the public really wants a solution at least as good as the ACA or better.Report
The strange thing is that the primary resistance appears to be from folks wanting to gut spending/coverage provisions even more than the current bill already does. 17% approval rating as it is. Only gets worse from there, seems to me.Report
Gerrymandered districts.Report
Yeah I want to laugh hysterically at the whole clown show but I’m afraid to because then somehow the universe will connive a way for it to pass and be blamed on the left.Report
Yep, it appears to be not only dead (the GOP lacks the votes), but apparently Trump is insisting they hold the vote anyways, I suppose to find out who the disloyalists are.
So yeah. Embarassing lost they can’t even pretend they’re just “rethinking” and will “try again later in light of constituent response and in-depth internal discussions on how to improve the bill”.
Just…setting political capital they don’t have on fire. “Look what we wanted to do, that 83% of Americans hate, but we were so incompetent we couldn’t even get it past the House. Because our politicians didn’t think it was bad enough.”Report
This is why I find it so interesting and wonder whether or not it will actually work: this is Trump cracking the whip. The implication is that a defecting Republican will face a primary challenge in 2018 from a Trumpista.
If Republicans fear that the President will deploy this means (or perhaps some other means) to retaliate against them, that appears to be the bill’s sole hope of passage at this point. That makes it a public measure of Trump’s true political strength.Report
Wow, yeah, when you put it that way it’d be interesting to see. It would still die in the Senate though, you can’t push Senators around the way you can Congresscritters and they can only lose 2 votes there (And Collins is most likely unswayable because word is she’s eyeing a run for Governor so she can tell them to pound sand and would get cred for it with her constituency back home).Report
Things to keep in mind:
Trump is polling at 37% and this bill at 17%.
The people killing the bill are the same people who are, bluntly, the most conservative and crazy folks in the GOP. These are people who are first to scream RINO and denounce compromise, and who were often last on the Trump train because it’s clear Trump isn’t a real conservative.
I do not think the Freedom Caucus is afraid on this one.
Trump’s threats, by and large, will be boosts to them. They’ll talk about how they held Trump’s feet to the fire, prevented him from “compromising with RINOs” and “selling out”.
So…unpopular President trying to whip support for an even more unpopular bill with politicians who can make political hay out of blocking him. Uphill climb, even for the Great Dealmaker.Report
Trump tells Ryan to pull the billl.
One issue I was wondering about in light of your analysis up there was whether Trump had enough political strength to compel Ryan to hold a vote which would be personally humiliating to Ryan and the GOP caucus. So I guess we have an answer.Report
My guess is that the vote counts were getting worse. Once the membership knew that the bill didn’t have the votes, no one was going to vote for a bill that presented such a perfect Democratic campaign ad.
Trump a threat? ha. House Rs are worried about the Koch Bros on one side and a district that’s only R+4 on the other.Report
I spent a few minutes looking for a quick summary of the Cassidy/Colllins Senate plan without luck, but – echoing Morat’s point up there about the ACA being a “best conservative” solution to healthcare issues in the US – I think the C/C retains most of the basic ACA architecture while including some provisions to strengthen individual markets and state budgeting/choices. If that’s where GOP moderates are regarding the R/R, and it has four GOP signatories at this point, then the current bill simply has no hope of passage.
If anyone knows the broad outlines of C/C or a good linky to get caught up to speed, please share!Report
C/C won’t go anywhere as a GOP only plan because the Freedom Caucus will vote against it en masse and The Dems wouldn’t buy into it and contribute votes unless they get a lot out of the deal which would move the bill so far to the left (like close to the center) that GOP leadership would be afraid to bring it to a vote.Report
I think that would depend on the specifics in the bill tho, no? Pure partisanship suggests that no Dems would get on board, but if the provisions in the bill fix problems that even Dems recognize then it doesn’t strike me as bad politics (and good policy taboot) to work with C/C backwards into the House.
I mean, it’s sorta a far-flung fantasy to think the two sides could engage in that much cooperation, but there are some things in the ACA that need fixed. Tho certainly not that it’s “going to collapse under its own weight”, which is a line I personally hope to never hear a politician say ever again.Report
The Democratic Party should oppose any plan that makes the ACA worse. C/C makes the ACA worse. Period.
If the Republican Party wants to make health care worse for people, they have a majority in the House, Senate, and the Presidency. They can go ahead and proceed.Report
C/C makes the ACA worse. Period.
I finally tracked down some stuff on it, here and here.Report
Yeah, Vox has a good explainer on it.
I mean, if this was the offer from John McCain in 2008 after he beat Obama, great! But it isn’t.Report
C/C is just a pick-your-adventure compromise (as far as I can tell).Report
Yes, it is. Question is, what does it do better and what does it do worse than the ACA. The above linkies specify a bit of that.Report
The description on Sen Collins’ site doesn’t do the trick?
TLDR:
1. Obama Care
2. Romney Care
3. I don’t care
Guys… the ACA isn’t the best conservative option for healthcare… unless you mean the best option the 115th congress can come up with.Report
“Patient Freedom Act”. Sounds good to me!Report
There’s no such thing as a “good” conservative health care plan that actually works in the real world. At best, you can get Singapore which uses use the horrible power of the state to force people to save money and also heavily subsidizes premiums and such for really low income people.Report
Why is a HSA mandate worse than an insurance mandate?Report
I’m not saying it’s a worse or better policy.
I’m just saying it’s not very much freedom or liberty if the people with guns who can shoot or imprison you can force you to save your money, that you’ve earned by the sweat of your brow.Report
Its marginally more liberty since you’ve got the option to spend it on any sort of healthcare related purchase you want instead of just insurance. We can also make it marginally more liberty friendly by making it a default with an opt out option rather than mandatory. But I suppose we’re quibbling there.
To be fair, I’m not that doctrinaire a libertarian when it comes to healthcare. Both my parents work in government hospitals and my father used to head the emergency department while my mother heads the renal department. Governments do sometimes do things better than private companies (though Singapore’s government hospitals are nominally privatised).The question is whether american governments can. A permanent civil service helps.Report
Because HSAs don’t help with big ticket issues and only really provide tax benefit to people who aren’t struggling to pay premiums in the first place?Report
HSA’s are useless if you’re poor. They’re not quite useless, but pretty close, if you’re middle class.
My company switched us all over to HDHP’s a few years ago. Which also happened to be the sickest year of my family’s life. I have maxed out my HSA contribution two years running (which was, bluntly, more than I could afford) and ended each year with it empty.
My first year my out of pocket was twice the HSA max. My second year it was only 20% more.
HSA’s are great if you’re rich. If you’re middle class you’ll end up trying to decide whether to contribute to an HSA, your 401k, and trying to play “guess whether it’s a cheap or expensive year” when picking between the “high, really high, ridiculously high” deductibles.
HSA/HDHP are great if you’re 25 and single and middle class. If you’re 40, with a family? They’re just a kick in the nuts.
Moving me to an HDHP, by the way, was the first time I ever had the “Can I ignore this? Can I even afford to have this looked at” conundrum. It wasn’t shopping between doctor’s for better prices, it was “Can I afford this procedure at all? I guess I’ll just suffer”.Report
I don’t know. HSA + subsidies seem like a more efficient way of funding than insurance + subsidies. Especially for pre existing conditions and other sure things.
The problem with the health insurance market is that it is a bit (though not exactly) like prisoner’s dilemma.
When everyone is on HSA’s hospitals cannot charge so much because people will just decide to suffer.
Once you get enough people onto a comprehensive scheme, hospitals can gouge insurance companies (because no one likes insurance companies) which then pass the costs onto you after skimming a nice profit for themselves. And since you’ve paid for the insurance anyway you’d be a sucker to not go for the procedure, no matter how much the doctor is charging the insurance company. And if you’re on a HSA while everyone else is on insurance, you feel the full brunt of that price so getting on the insurance looks like a bad idea.
The good thing is that when the hospital costs are low (with subsidies where necessary) and everyone else is on a HSA there is little incentive to get comprehensive insurance.Report
They’ve done actual studies on HSA’s, you know. And what they found was pretty much identical to my experience: People don’t become smarter shoppers of healthcare, they just start foregoing necessary care because they can’t afford it.
Until it becomes disastrous.
So yeah, HSA’s sound good in theory. In practice? They suck. Prices aren’t transparent, so you can’t comparison shop. There’s no fixing that either, because when you’re sick the price doesn’t even materialize until they know what’s wrong with you — a process itself with a price that can’t be quantified, because they don’t know what’s wrong with you.
HSA’s are like communism. They sound good, but fail utterly. I’d prefer not to take part in someone’s stupid ideological experiment that doesn’t work because they’re sure that, someday, it’ll magically kick in. Any minute now, the magic will happen.
In the meantime, I’m putting off correctable stuff because I can’t afford it. And my OOP max, despite being as low as I can get it, is high enough that a significant enough run of bad health could bankrupt me.
Fantastic plan. Can’t wait for the free market ponies to fix it.Report
In my experience, HSA’s are good for things like getting a good pair of glasses that standard vision insurance will never fully cover, or for paying for that unexpected dental issue, that standard dental insurance doesn’t fully cover. They are not very helpful in defraying costs associated with an ER visit and any follow up tests or procedures that may come from that. One ER visit or unexpected issue can potentially max out the HSA and if that happens in January you are pretty screwed for the rest of the year and things like new glasses or getting that mole looked at tend to get put off. I think of HSA’s as a nice extra, but I would never, ever think they could effectively replace more traditional insurance.Report
As I noted, studies have shown they don’t reduce prices via competition — but by delaying necessary care.
They incentivize penny-wise, pound foolish healthcare choices.Report
If there’s one thing the GOP has screwed up about its response to the ACA, it’s deciding en masse that mandating coverage is bad and un-conservative. Making that part of their orthodoxy means that they either can offer nothing worthwhile, or they can embrace something like Berniecare [1,2,3].
“The ACA is a Republican plan!” is an overstatement, but it’s a lot more Republican-looking than most things that could actually work. By making, “Repeal Obamacare!” the alpha and omega of GOP healthcare policy, they’ve basically ceded entirety of the debate to Democrats.
[1] Or, you know, an NHS-like “VA for All” system which I’m sure would thrill Republicans even more than “Medicare for All”.
[2] Maybe the GOP could negotiate to include copays, coinsurance and/or deductibles in Berniecare. Those might even be good ideas! But still.
[3] Or they can work on stuff that looks marginal, like the FDA, et c. They might even be able to implement some good ideas there, too.Report
The cynic in me thinks that the GOP wants this to fail because they received endless political capital from railing against Obamacare/ACA.
There are parts of the ACA that are not perfect. The subsidy cut off is at a weird place where there are probably a lot of people who make too much to receive one but not enough where they are not feeling a pinch. There are also aspects that only a wonk/economist can love like forcing people to shop around for insurance plans every year to get the maximum utility of competition. Also constant income checks for people with subsidies.
People don’t want to do this. They want to stick with their insurance and their providers. A lot of people on the wonky side like to talk about how insurance chained to employers is a bad thing because it decreases job mobility but I suspect most people don’t want job mobility. They want one employer with a semi-paternalistic relationship for their working careers and then they want a nice pension and retirement dinner.
But the GOP is in a bind because most if not all of them sincerely believe that it is not the role of the government to help people have healthcare or to subsidize healthcare. There is nothing wrong with believing this but it is a political non-starter and the GOP knows it so they always have to do these weird dances except for people like the self-titled House Freedom Caucus.Report
“The cynic in me thinks that the GOP wants this to fail because they received endless political capital from railing against Obamacare/ACA.”
Obamacare is the new abortion?
WOW that came out strange…Report
Stuff that strikes me as likely to happen:
1. The bill actually passes, believe it or not, and goes to the senate where it sits around to die in committee.
2. The bill doesn’t pass, Trump turns on Ryan, and then people really, really, really start fighting with each other. (Like, Ryan steps down as speaker kinda fighting.)Report
Ryan stepping down as Speaker strikes me as about the worst possible outcome from the bill’s failure for the Republicans. It would leave them a leaderless majority — who do they name as Speaker after him? They already passed on Kevin McCarthy being Speaker because when he was next in line the last time, he blurted out the truth about what all of those Benghazi hearings were really about, ooopsies! So who, then? The majority whip, Steve Scalise? Really? That Steve Scalise?Report
It’s not surprising that these people don’t remember why Ryan is the Speaker, but it’s still pretty funny that they think replacing him will be easy.Report
Remember, the Speaker doesn’t have to be a member of Congress.
Give Newt the job again. Make him put up or shut up with his Twitter Trumpeting.Report
Better yet: since every Republican is going to hate the Speaker anyway, just save some time adjusting and make Obama do it.Report
Alternatively, Prince Harry doesn’t have anything else better to do. He’s exactly Trump’s kinda dude. Born rich, frat boy antics in his youth, Afghanistan combat vet, good looking girlfriend.
And, nearly two hundred and fifty years later, you gotta think the British Royal family knows how to handle an American Tea Party.Report
Brilliant, especially for the antics when he asks to dissolve Congress and hold a snap election.Report
His Gran’mum would warn him not to take it; it’s a trap.Report
Burt Likko for Speaker! I’m sure that it will be entertaining…Report
My God, what did Burt do to make you wish such misfortune upon him?Report
The job has only been hell for Boehner and Ryan because they have two roles: Speaker and leader of the majority party. The latter is only tradition. Burt doesn’t have to take it on, and I’d advise him not to. Then it becomes a much more interesting job. After all, what’s the worst that can happen to him — they vote him out? When that happens, he can make millions on the lecture tour.Report
To quote William Mulholland: “I would rather give birth to a porcupine. Backwards.”Report
Come on, man. If they offered you the job even after you say that you won’t simultaneously be the leader of the majority party, you could make it fun. Make me your chief of staff and I’ll make if fun for you.Report
Well, if I don’t have to be the leader of the majority party as well as the parliamentary captain of the House then it’d be…
It’d be better, but it’d still not be the right job for me. I belong on a very different kind of bench.Report
Which part is backwards? The porcupine or the birth?Report
ISTR that they asked Pericles on the Potomac to take the job before turning to Ryan, and he said no.Report
I don’t remember who you’re talking about. The heir apparent was supposed to be Cantor, but he got primaried. Boehner left anyway. McCarthy was the first choice, but the GOP caucus rejected him for the reasons Likko stated (and talk radio didn’t like him) Then Ryan’s name was floated, most everyone agreed (there was another name I forget floating around from the Tea Party/Freedom caucus but he didn’t expend any effort to actually try for the job) so Ryan became speaker.
Who am I forgetting?Report
Newt! I remember a story (which I can’t find, natch) that involved him turning down the Speaker’s gavel after Boehner quit.Report
Oh, I didn’t realize that ‘get the Speaker from outside of Congress’ was ever seriously considered by anyone other than internet and media people.Report
Oh, I don’t disagree with any of that.
It doesn’t strike me as any less unlikely, though. If Ryan wanted to make such a big deal out of Trumpcare as the first major bill to pass and then he bungles it… That’d be a “you’re fired” moment on the Apprentice, wouldn’t it?Report
I would love to be rid of Ryan. He’s a wily bugger with a pretty face (on the politician curve) and a good “aw shucks I lurv the poor” shtick. I’d much rather they have a crooked deranged old goat speaker to reflect his party more accurately.Report
Fingers crossed!Report
Remember last time we hoped the other side would pick a nut?Report
Ryan is a nut, he just has a pretty shell. I’d rather one without one.Report
Possibly moot at this point, but isn’t this supposed to be the “phase one” bill that the Senate can handle under reconciliation rules, hence immune to filibuster? Certainly there’s been lots of speculation about whether the Senate parliamentarian would advise that some parts don’t fit under the rules, and whether the Republican Senators would vote to overrule her.Report
Yeah, as Chait says the whole grand plan is gonna implode. My bet then is next:
-Ryan runs around and around on the border adjustment tax bundled in with tax reform (cuts), it goes down in flames.
-The GOP says fish it and pulls a GWB: passing another deficit exploding tax cut that simply expires in a few years.
Or best case scenario:
The GOP runs in circles squawking and bumping heads with each other for two years accomplishing nothing until the disgusted electorate throws the bums out.Report
They’ll get the deficit exploding tax cut, natch.
They’ll get increased defense spending, obvs.
They won’t get Trump’s stimulus bill.Report
I wonder what Trumps constituency will get?Report
The Wall.
Trade reform (it’s already happening. Carrier!)
ICE agents rampaging thru cities deporting “illegal” mothers with small US born children.
Enhanced vetting of Mooslams…Report
But there’s also a trillion dollars of infrastructure spending over the next ten years, for what that’s worth (which turns out to be not nearly so much as it sounds like, by the time shovels actually hit dirt).Report
Well I’ll believe there’ll be a wall when it’s paid for, not before.
Trade theater maybe but I’m skeptical about trade reform, unless Ryan goes down then maybe- who knows?
Yes on the being meaner to minorities and muslims but I like to think even Trumps base can’t survive on schadenfreude alone.Report
CNN is reporting that Ryan has pulled the bill.Report
C-Span 1 also. Ryan to hold a press conference at 4:00 ET.Report
Some thoughts on failed ultimatums:
– Ryan is pissed, humiliated, and marginalized.
– Trump actually comes outa this smelling good, really good depending on how he plays it going forward: he went to the floor several times over successive days to work a deal. It’s not his fault cats can’t be herded.
– The GOP looks like a bit of a joke, right now.
– Any future proposed revisions to the ACA will be less radical than the current bill propose.
– Finally, moving forward I think Trump moves away from a dubious (in my view) strategy of working exclusively thru the GOP to get bills passed on strict party line votes. He’ll appeal to the Dems when it suits his purposes – get people in a room, work a deal, find consensus to pass legislation, rinse repeat, while also increasing the beatings til moral improves.Report
Ack, no. Trump looks like the man who couldn’t make the deal. He claimed he’d pull it off, and didn’t.
No matter who he blames, the end result is: Trump couldn’t do it. He couldn’t make the deal. He’s the face of a party that, after 8 years of “REPEAL AND REPLACE” couldn’t get it past their hefty House majority.Report
Ack, no. Trump looks like the man who couldn’t make the deal. He claimed he’d pull it off, and didn’t.
Well, we’ll see. I mean, all I can say is not only that *I* don’t think this is his fault (I think the opposite in fact, that he did yeoman’s work trying to get it done) – but I think it will be a meme without any political bite going forward.
Another way to say it: this episode exposed GOP dysfunction and not Trump incompetence.Report
Trump gets to say that he would have signed whatever Congress put in front of him.
“But he couldn’t make Congress do its job!” strikes me as less likely to reflect poorly on Trump than on the GOP.
Hell, he could point to the dozens and dozens of straight up repeal bills the Republicans sent over the last 7 years to Obama and ask “why didn’t they just pass another one of those?” and come out looking better than the GOP did.Report
Alsotoo: Trump ran on an anti-establishment platform of which ACA R/R was only a piece. The House GOP ran only on a R/R platform. And when given their big chance they couldn’t deliver. Which makes Trump’s anti-establishment views look even more accurate and more prescient.Report
Another way to say it: this episode exposed GOP dysfunction and not Trump incompetence.
Sure, but he’s the de facto leader of the GOP, and his ability to exercise any sort of message, combined with the fact that his Administration leaks like a shotgunned beachball, really don’t help him here. A guy who’s not Trump might get more of the benefit of the doubt, but I’m not sure a guy who’s not Trump would have gone along with Ryan’s too-clever-by-like-seven-eighths plan.Report
he’s the de facto leader of the GOP
Only nominally. He won the primary by being fundamentally anti-GOP. He’s not GOP. He’s not even a conservative. He just ran on that ticket.Report
He needs large components of that ticket to get anything done or have any shot at reelection*. If the GOP goes down in flames Trump would be in a bit of a pickle. Assuming (and it’s a not small assumption) that an unfriendly Congress wouldn’t find something to impeach him over the only way he’d get anything done would be by cooperating with them on their priorities which would lose him votes from his side and not win him votes from the left (why vote for a big orange faux Dem when you can vote for the real thing?)
Now granted, Trump suffers from the GOP being discredited and disgraced less than the GOP suffers from it; but he still suffers.
*assuming he tries for reelection.Report
He’s the guy who was supposed to do things different and right. He’s the guy who was supposed to cut through all the politics and bureaucracy and corruption and fraud and waste. He’s the guy who was supposed to make the best deals. Oh, and he was the guy who was going to repeal and replace the failed and awful Obamacare.
Those things aren’t happening and today’s legislative failure demonstrates that. And that is what makes Trump look bad — whether reasonably or not.Report
He’s also the guy who said the replacement would provide everyone with insurance, with better coverage, lower premiums and deductibles, and strengthen both Medicaid and Medicare.Report
“It’s an unbelievably complex subject. Nobody knew health care could be so complicated.”
Add: You know, I love to kid about that for all the right reasons (eg., that anyone with a) a functioning neuron who was b) paying attention during the ACA debates already knows this. But I think it’s also funny because I think Trump really DID believe that healthcare was an easy fix. Mostly because he views politicians with such contempt that he attributed to them the worst possible motives in the construction of the ACA.Report
I have always been curious about — and far, far too lazy to investigate — how complicated a “Medicare for all” single-payer bill would be. Off the top of my head it would probably be quite long, but mostly because of the number of things currently in statute that would have to be repealed in some fashion — Medicaid, CHP+, the VA, Tri-Care, employer-provided insurance for federal employees, tax-free employer share of premiums in the private sector, HSA stuff, etc. Add in transition stuff to deal with dislocations because a significant portion of GDP that currently flows through private insurance companies no longer does so.
But a different kind of complexity than Trump was referring to.Report
“This bill is thousands of pages long, it must be bad!”
“This contract is only 10 pages? This is a 70 million dollar deal between three companies. Who wrote this PoC? Nobody writes something bullet-proof in court in 10 pages, not for something like this!”Report
“We’re gonna put a loooootta health insurance workers out of work.”Report
I’m starting to think you’re a Mayer Daley operative: You’re not here to create disorder, you’re here to preserve disorder.Report
Well, I was more thinking about how many people would have whooped and hollered at my, theoretical, line compared to the one that it was a tribute to.
I mean, a real and serious health care reform would reduce costs by, among other ways, reducing unnecessary overhead.
No more people whose job it is to call Aetna and re-submit claims! No more people whose job it is to send patients a bill explaining that the urine test was billed incorrectly and could they please send $.75 to the following address!
We’d be a lot better off, all of us, without these barnacles attaching themselves to the ship of health care.Report
@michael-cain
I kind of mentioned it in passing below but the way you’d have to start is by opening up Medicare Advantage and phasing out parts A and B over time. After that you’d start bringing in healthier working people on Medicaid, then finally dual eligibles who are the most expensive to cover. The various markets need to be consolidated. Once you’ve done that improving the incentices becomes easier. What I’m not sure is what would happen with employer backed plans. Maybe it would die out on its own but it would probably need to be regulated away which would be painful, and might never be possible politically.Report
And so the Republican coalition has been exposed as the undisciplined rabble it is. Of course it does suck that we will probably have to sit around at least another 4 years for a chance at fixing some of the major problems with the ACA, assuming none of the state markets fall into crisis beyond where they already are.
Part of me kind of wonders what a Trump presidency would look like with a Democratic majority in Congress. Not to be overly optimistic but maybe he’d sign a reasonable reform bill as long as he got a lot of the credit.Report
S.B. 877.
The Donald J. Trump Fabulous Beautiful Healthcare Freedom Act For Everyone Act. Introduced by Senators FRANKEN and SANDERS.
Special rule for consideration of S.B. 877: No Member of Congress may refer to this law as providing “single-payer health care” even if that’s what it really does.Report
Wouldn’t even have to go that far. Opening Medicare Advantage to people under 65 and consolidating the state exchanges into a single national market is the next logical step. It’d even sort of be in line with his promises and might make imposing some cost controls less painful. You’d also get rid of these artificial member populations that are impossible to insure profitably in places like AZ.Report
“Totally Not Single Payer” health care still seems a possibility to me, albeit a small one. It would seem more likely for him to go the Dems on the down low and have them squawk and scream the whole way but pass it in the end. He would probably have to muscle onto the Dem ticket if this happens before his reelection in 2020, not so much after.
Two proposals for title names:
Great American Insurance Network (GAIN)
Make America Great In Care (MAGIC)Report
It’s called AmeriCare and it’s totally a thing. Vox explainer here.Report
I think my proposed names are better. You want the big guy to sign off? Pimp his brand. I don’t care about credit, only results. If it gets us to a broader, more efficient system you can call the the “Joe sucks donkey dick” plan and I will sign on.
This election has taught me that branding is one of the most important parts of politics.Report
Looks like Trump is trying to blame the Democratic Party for not going along with this. Now the question is whether this can stick. Certainly with his most partisan supporters it can….Report
Is he blaming them, or back-handedly inviting them to get on board with contributing to revisions?
Do you think he’d work with Dems to pass a bipartisan reform bill? (I do.)Report
He might but:
A) GOP leadership would have to agree to bring it to a vote (and then it’d pass with lotsof Dem votes and some GOP votes). That’s involve ditching the Hastert rule and probably would cost them their jobs. I don’t see Ryan or McConnell doing it. Ryan is a true believer and the wily Turtle loves his job way too much to risk it for that kind of thing.
B) I struggle to see the incentive for the Democratic Party to play ball on this. Come forward, fix problems then let Trump and the GOP reap the credit? I mean yes on policy that moves things in potentially beneficial directions but politically that seems really problematic which could eventually empower Trump and the GOP to do whatever they want. That’s without even talking about how much of the bigger party the Dems would have to be to do that after all the years of the GOP’s remarkable antics. That’s one hell of a turd sandwich to swallow for some (likely) incremental improvements.Report
So, are you saying Dems should partyline oppose a
stimulusinfrastructure bill that would put USAmericans to work improving our bridges, roads, airports, etc, because it would make the GOP look good? Shouldn’t we encourage the GOP to look good in exactly those dimensions?ReportOh it depends on the issue. For infrastructure it’d depend on the details. If it’s a genuine infrastructure bill with a plausible method of paying for it (or an agreement to debt finance it) then I’d say that’d probably be worth playing ball if for no other reason then to force the GOP leadership to choose between Trumps constituency and their republitarian braintrust and moneytrusts constituency.
On healthcare reform I could see the Dems cooperating to fix the more jiggery pokey bits of the ACA but anything beyond that? Better probably to not cooperate.
On tax reform? Probably blanket oppose unless Trumps talking about throwing the GOP orthodoxy out the window. Trade? Most likely blanket oppose.Report
He would, but he have to overrule his VP, his HHS sec, and his Chief of Staff.
Remember the Supreme Court case where they wound up ruling (incorrectly imo) on the intent of some ACA wording instead of the plain text because a simple short bipartisan to fix the actual wording was impossible?
There is currently no coalition in Congress that exists that would be able to ‘fix’ the ACA without some kinda poison pill from either side
The only model that works is when Henry Paulson had to go to Pelosi to pass the initial TARP after the first one failed. But those were extraordinary circumstances, with the Dow losing several hundreds of points a day and just a couple days away from a liquidity crisis. There’s nothing like that now, and there’s no downside for the Dems to just ride out the status quo – even if, especially if, everything blows up like Trump claims.
Because the other precedent was Republicans claiming Iraq wasn’t going badly, it was only the Dems talking things down – until people finally got sick and tired of ‘not winning’ and created an unprecedented Democratic wave in the 2006 election.Report
He would, but he have to overrule his VP, his HHS sec, and his Chief of Staff.
Well, he already did, then. He invited Dems to come to him with an ACA replacement plan. Granted, he framed it as resulting from the ACA collapsing under its own weight and Dems’ resulting desire for change.
Or more precisely: he didn’t overrule them. He went outside of normal channels.Report
Trump…says a lot of things. At the end though, there is no combo of (all or some) Dems plus (some) GOPs that is willing to pass anything vis a vis healthcare.
Maybe it changes if the Dems take Congress in 2018. But I’m in the camp that today made that less likely, not more.Report
K,
I agree with that. You’re making a valid point about the reality structural politics in a formal setting like Congress. I’m making a point about retail politics. Trump wants to blow up structural politics and return it to retail. (Well, something like that anyway…) And that sentiment or view (cynical or not) is what got him elected. He’s not going to let it go.
And so the battle rages on.Report
Trump says he wants to blow up structural politics and institute a new retail politics, and on paper, he’s in a unique position to do so. (As said elsewhere before, he’s playing with house money)
But he lacks the discipline to actually do it. And he doesn’t really care enough to make any serious effort towards that end.Report
I actually agree with that too. Trump is good at low level corruption and grift. But that doesn’t mean he isn’t going to strive for something bigger. And it certainly doesn’t mean he won’t succeed.
I mean, if you think that leaders of each party view Trump and Trumpism, in part, as a threat to their own power structures and paradigms, then you’re gonna get a lot of inter-political resistance outa self-preservation, irrespective of policy agendas. The gatekeepers are gonna guard those gates!Report
It seems to me that this is managing his future downsides.
First, he is trying to block the opposition party from being able claim no responsibility for the current problems. Fair or not, the Democrats can be criticized for not being part of a solution. In essence, they fiddled while attempts to improve healthcare burned. He wants to publicly shift as much of any blame for issues in the healthcare system to occur in the next while on the Democrats as possible. The ACA is broadly seen as wholly a Democrat project. Even if the Republicans do nothing to fix the problems, that the problems exist in the first place can be said to be the Democrats fault. He needs to manage his exposure to the downsides of any horribleness to follow. This is why all the surragets are out hammering the line “He did everything he could.” He can’t dump it all on Paul Ryan and the house GOP, since he has to work with them for now. Shifting to the democrats is straight up damage limiting.
Second, one thing he has been quite consistent on is the willingness to work with people that want to work with him, albeit on his inflexible terms. It really costs him nothing to hint he will work with Democrats, since he knows that the congressional delegations are extremely unlikely to. If by some miracle the Democrats take back House and/or Senate during his tenure he will have to work with them. So, there is a downside to just poking them in the eye because he can. The only upside is during campaigns when it fires up voters. The next round of elections for him is a long way away, the nuance of this debacle will be long forgotten. He is not going to harm relationships when there is no present battle to be won or deal to be had.
Finally, it burnishes his leader/independent/maverick/whatever credentials to say he will do whatever is best for the country regardless of who brings the deal to the table. There is significant truth to this in his character. He does not give a fuck who brings him the deal, if it is a good deal… it is a good deal. There is no downside to broadcasting to opponents on this failed deal that is over that he is open to another deal, if it is a good deal.Report
This from Jonathan Chait matches my view for the most part –
“The right’s insoluble problem is that people who have insurance like it. Employer-sponsored insurance is popular. Medicare is popular. Medicaid is popular. To the extent that the exchanges in the ACA are not that popular, it is because they are less like those forms of insurance and more like the kind of insurance conservatives prefer — they have higher deductibles, more price discrimination between old and young, and more market competition. Any employer-sponsored insurance plan is going to cover essential health benefits. It’s going to charge the same price to the young and the old alike. In other words, it is going to spread the risk of needing medical care throughout the population it covers.
Conservatives disagree philosophically with the very concept of insurance as most Americans experience it. Insurance means spreading risk, which is a form of redistribution. Republicans postured against Obamacare from the left, denouncing its high deductibles and premiums, and promising a better, cheaper plan that would cover everybody. Their plan, inevitably, did the opposite. All politicians overpromise, of course. But the Republicans did more than overpromise. They delivered a policy directionally opposed to their promises.
It is not possible to write a bill that meets public standards for acceptable health-insurance coverage within the parameters of conservative ideology. “Report
@jesse I hadn’t seen that piece, but the bit you quote is damn good — especially the part that you highlighted. I’ve been damn confused these past few months by various arguments that various ACA coverages are “redistribution’s of wealth.”Report
It’s easy enough to hear it if you listen. “Why should my insurance dollars pay for mammograms and pregnancy? I’m a guy!”. “Why should my insurance dollars pay for fat people? I’m in shape!”. “Why should my insurance dollars pay for sick people, I’m healthy!”.
It’s all versions of the same thing — a belief that “insurance” is — or should be — a savings account, wherein you place your dollars and you use your dollars and nobody else gets to touch your dollars.
Risk spreading is redistribution. Until, of course, the expensive stuff happens to them.
\Report
Frum bookended his famous “Waterloo” post with another Waterloo. https://www.theatlantic.com/politics/archive/2017/03/the-republican-waterloo/520833/
I think he’s too fatalistic. I suspect the GOP will probably take another run at the ACA so I don’t share his confidence the bill will survive but it’s a helpful point of view from a conservative moderate (albeit a bush era neocon).Report
I think he’s too fatalistic.
I think he’s too optimistic. 🙂
His article is incoherent. Even if the GOP doesn’t get around to HCR in this congressional cycle they’ll return to it soon enough for the reasons he wrote at the beginning of the article: the GOP-mouthbreathers have learned that being an angry opposition party is where the money’s at. And GOP CCers elected by angry voters will surely follow suit. Wash, rinse, repeat. Maybe one of these times they’ll get lucky, tho. Who knows. But I’m sure they’ll keep
yammering about ittrying.ReportThey are going to want to get the things they really want, like tax cuts and big business friendly regulatory cuts. After that and surviving whatever the Russia/Trump scandals turn into i doubt they will want to snuggle up to the HCR land mine. They also have the debt ceiling to cope with.Report
Yeah, my wife and I were just talking about that. Given all the other big ticket items we are both thinking HCR is done for this congress. Hard to see how they fit it in while also trying to pass other major items. Never know tho.Report
The longer they leave it, unless the ACA exchanges destruct on their own, the harder it’ll be for them to try and get rid of it without having something to replace it with.Report
The polling next week should be interesting to say the least. I think we’re going to find out precisely how low the various players can go.Report
the harder it’ll be for them to try and get rid of it without having something to replace it with.
From what I understand, the biggest procedural problem the GOP has to deal with is that R/R can only be rolled out in phases. The only portions of the bill they can repeal are budgetary provisions consistent with reconciliation. I think the long game best case scenario was that once the architecture of the ACA was gutted to the greatest extent possible under reconciliation more folks would get on board with actual (capital R) Repeal/Replace.
Of course, the logic of the problem presents as exactly backwards from a legislative and functional pov. Folks were encouraged to massively disrupt the ACA architecture without any replacement plan in place. In fact, I saw at least two GOP CCers (no votes) complain that the House should be including phases two and three into the initial Ryan Repeal bill (I think they meant separate but joined, or at least I hope so). I understand the concern: I wouldn’t want to vote for movement without knowing what the destination actually is either.
Anyway, the problems the GOP faces wrt R/R are substantially greater than the Dems faced during the ACA passage: they don’t have a filibuster proof majority in the Senate which means they weren’t constrained to cobbling legislation piecemeal to accomodate the limits of reconciliation.
Politically, each and every one of them shoulda known the promises were effectively impossible to achieve, not only because they’re pie-eyed, but because Senate rules work against them. (Unless they go nuclear.)Report
Here’s another way to say it:
Unless they go nuclear, the GOP simply cannot pass a comprehensive R/R bill since Dems will filibuster post-reconciliation phases 2 and 3 or a comprehensive bill. Which leaves the reconciliation bill hanging out there in space like an evil but redeemable puppy.
Which is perhaps why everyone in the House was determined to make sure the reconciliation bill actually delivered. It was likely all they were gonna get.Report
I’m curious how much damage this has done to the GOP. Both with independents, and internally.
They have Congress and the White House, and this didn’t even make it to the Senate to die. It didn’t even get a vote in the House. The hard-core partisans have to be furious.
There’s been discussions of political capital here before, but the quick version is: The less popular you are, the more likely voters (and the media) are to look for the “catch” in your proposals, to look for the “bad”. Because you’re disliked, the stuff you propose carries forward that dislike. (The opposite is true if you’re popular).
So normally the GOP base swallows trickle-down tax cuts, or accepts the massive lopsized nature of tax cuts. But how are they going to feel about these issues if they’re angry with their own party as corporate sell-outs?Report
As damage goes, I’m unsure how to measure it in this particular case because their particular “fix” to the PPACA sucked.
Did *ANYBODY* like it? Anybody at all? Even donors?
If it’s the case that everybody disliked the bill and then it failed because it couldn’t pass, that’s… well, that’s an indicator that the Republicans are stupid and feckless and have been posturing for the last 7 years.
But they failed to do something that nobody wanted them to do.
Which is a weird kind of failure.Report
To many R’s believed fixing health care was simple and easy. Many believed they could cover everybody better for far cheaper with no muss or fuss. Plenty of others never gave a crap about covering people, they don’t care about tens of millions not having access to health care they just couldn’t admit openly ( or at least to often) But plenty of R’s wanted a fix and their failure was not a surprise.Report
The other weird part is how close they came to succeeding. The bill was stupid and everybody hated it, but there was a nonzero chance that they would pass it anyway because they’d painted themselves into a corner by making nonsense promises for years.Report
Yep, debt ceiling now — Treasury has already hit the limit and is in juggling mode — and spending authorization next month. The current continuing resolution runs out at the end of April 28th. Odds on Ryan’s Speakership surviving those two?Report
The practical and ideological and political conflicts inherent in dealing with the debt ceiling should mirror matter and anti-matter pretty well.Report
I’m not following the logic at all. When Obama was in the White House, staging lots of ineffective votes had upside: the Republicans could point to all the simple repeal votes they passed and blame Democrats for nothing changing. Failing to pass bills doesn’t have the same upside; it just makes them look weak.Report
Did you read the Frum piece?Report
Here’s a good article about splits in the GOP which supports Frum’s basic thesis. It’s a good read. Particularly relevant is this quote:
[Ohio GOP Rep. David] Joyce made a simple, binary choice about Obamacare: “The American Health Care Act was not a better solution.”
Political churn is starting to beat the hell out of GOP orthodoxy.Report
There a plenty of throughly stupid quotes coming out from R’s over this clusterfish but this is epic:
Rep. Joe Barton (R-TX) admitted as much as he left the meeting Friday. Reporters asked why, after Republicans held dozens of nearly-unanimous votes to repeal Obamacare under President Obama, they were getting cold feet now that they control the levers of power.
“Sometimes you’re playing Fantasy Football and sometimes you’re in the real game,” he said. “We knew the president, if we could get a repeal bill to his desk, would almost certainly veto it. This time we knew if it got to the president’s desk it would be signed.”
(From TPM)Report
Cleek’s Corollary: Republicans can’t govern simply by opposing Democrats, updated daily.Report
I’m guessing we’ll need a few thousand more tests of that theory before it sinks in.Report
I commented on this on another blog.
They got lazy. Six years of knowing that they’d get vetoed. They should have been doing the groundwork – realistically, having their staffs do the groundwork – all along. They should have had a big red book they pounded their fists on for the benefit of CNN “This is our plan! If Obama would stop overriding the will of the people with his cowardly vetoes, we could implement it!”
But they got lazy because the veto would always be there. And now that it isn’t, they’ve forgotten how not to be lazy.Report
Maybe we’re looking at this failed ultimatum the wrong way.
Kasich portrayed Friday’s failure for the bill as a fresh start: “Now we have a chance to do it right,” he said in a Twitter message.
Yeah, that’s it. Now that the last seven years of repeal/replace are behind them they can move forward with a clean slate and do it right. Easy peasy.Report
The hard part is that they burned their 50 votes in the Senate bill for 2017. They only get one per year and all signs point to 2018 being used for tax reform. It is rough spot for them, either get something that will get 60 votes in the senate or deal with the failure to repeal Obamacare in the mid-terms.Report
Obama invested over a year in passing the ACA. Ryan’s (and McConnell’s) calendar required getting this bill done in a month. They were making enormous changes in the bill on the night before the final vote! By day 36, Trump was indicating that he was done with ‘negotiating’.
That’s just extraordinary incompetence. I can’t think of a single major legislative effort since 1980 that had so much publicity and commitment behind it that failed so spectacularly and quickly. Even Soc.Sec. privatization lasted longer (or so I recall).
Going forward: The press is going to have a field day ripping into their (self-created) model of Ryan as some kind of deep wonk, and of Trump as a closer. Tax cuts just got much much tougher. So does comprehensive immigration reform and building the Wall.
btw, this process utterly vindicates Nancy Smash Pelosi as one of the great House Leaders.Report
To your last point I have to say that Pelosi and the Dems put the lie to Ryan’s “we’re learning how to be a ruling party” nonsense. When Obama won the election, every Dem in every committee was writing and voting on legislation that hit the floor and was passed by the House. The ACA took a bit longer, of course, but the flow of passable, actionable legislation was unimpeded even then.
I don’t have any idea what he means by “learning how to be a governing party” except as an admission that the GOP was defined by Cleek’s Law for the last 8 years.Report
That’s the issue – whether you like Democrat’s or not, we’ve got plans. We’ve got bills. We’ve got ideas. They may not be good ones, but on Day One, we’ve got a stack of stuff to point too that we’ve promised to do so something about while out of power.
Meanwhile, the GOP has spent the last 8 years bloviating, passing simple repeal bill they knew would die on the fine. I somewhat understand that the nomination of Trump made it a little more difficult to roll out your standard issue GOP package of bills during the election, but it’s complete political malpractice that the GOP really had nothing on Day One except repealing a bunch of regulations…and that’s about it.Report
I dont see how Trump made it any harder. He was hard charging to get stuff done. His pen was on fire ready to sign stuff. All they had to do was give him a way to sell it to the population at large and he would sign anything. Seriously, as long as you could convince him that people would like him for it, he was on board.Report
This is a good thread on how a president can shepherd a bill :
https://twitter.com/LeonHWolf/status/845987558840553472
But fundamentally: (1) Trump had no interest in the policy, so he couldn’t sell it to the public; (2) he had squandered whatever clout he had after inauguration on personal spats, so he couldn’t sell it to Republicans; (3) he wanted it done quickly and without negotiation, so he got in the way of his own allies.
I have a feeling we’ll be seeing this pattern a lot.Report
All that may be true, but the fact remains it was a shite bill that no one liked, including the GOP CCers. That kind of institutional incompetence gets pinned directly on the national-level GOP’s pandering bullshit, direct lies, and obvious cynicism in placing partisan politics above even the slightest sincerity in taking governance and policy seriously. They’re a bad fucking joke that just won’t die.Report
I saw a quote from Tom Cotton this morning talking about what a great salesman of the ACA Obama had been, how long the Democrats spent debating the bill and selling it to the public. It made me think that [Republican presidential hopeful praising Obama for transparency with the public] is one of those red lines that, once it gets crossed, means the GOP is gearing up to have a very different relationship with Trump than they had so far. Cross enough of those lines and the president starts being less interested in a second term.Report
You’re not cynical enough. That’s laying the groundwork for “Once again, we are not going to be able to raise the debt ceiling without Democratic votes. Maybe not even in the Senate. So, um, guys? Can you go ahead and vote our way to keep the lights on?
Even though, of course, we’ll use these votes against you at election time?”
If Cotton’s praising Democrats, he’s afraid the Freedom Caucus is about to start blocking basic governance again.Report
If you’re interested in that line of thinking (well, the first part of your comment anyway) this article is pretty spot on, IMO:
Paul Ryan Failed Because His Bill Was a Dumpster FireReport
Yes, I agree that the bill was shite. In fact, it was precisely the kind of Clintonian policy overload that Trump ostensibly ran against: a bunch of buzzwords that don’t add up and do not clearly benefit anyone, coupled with major giveaways that obviously benefit special interests. But someone who calls himself the deal artist – the negotiating table his canvas and an ultimatum his brush – should have either let the thing die in committee (and blamed it on Ryan) or pushed it through the House and let it die in the Senate (and blamed it on McConnell). This outcome was the worst possible deal because it revealed how little power Trump and Ryan actually wield.
And the key thing is that this [clap] will [clap] happen [clap] again, because Trump just doesn’t do policy and his team is a confederacy of dunces. I mean, he went to the freedom caucus – red meat Republicans that routinely win in landslides – and threatened them with midterm opposition! As if Louie Gohmert (who got 74% of his district last election) is going to be concerned about looking like a squish because he didn’t sign on to Paul Ryan’s healthcare bill. I would love to see the actual whip count on this because from all the reporting it sounded like Trump was actually *losing* Ryan votes with these meetings. Trump appears to have no understanding of what to actually *do* in a negotiation with Congress, period. He hasn’t even reached the level of bad negotiator, he just doesn’t even realize a negotiation is happening or what the possible terms could be.Report
Obama lied about it and that helped make it sound better than it really was.Report
… which should have made it that much easier for Republicans to undo the horrible no good law Obama signed. Yet after 7 years of work they somehow managed to put together a reform bill that polled worse than gonorrhea.Report
Let’s be clear, tho. It’s primarily the democrats fault the Ryan bill didn’t pass. If they only realized what a no good dirty lowdown dastardly Act the ACA was, they’da been right on board. But they’re obviously too partisan to cooperate in dismantling the ACA to vote for a bill that even conservatives didn’t like.
Conservatism cannot fail, it can only be failed by Democrats not voting for conservative legislation.Report
Could thing we have a president with too much integrity to do that now. How are the promises he made on health care looking? Are you going to hold it against him the same way you held it against Obama?Report