Wednesday, June 28, 2017

The little big reveals:
Why Trumpcare is already DOA


IT WAS A blink-and-you’ll-miss-it moment in the current debate over the future of health care in the United States, one that seems to suggest what’s coming next in this comic saga of a manqué presidency. It came, like so many moments of accidental revelation do lately, from President* Donald Trump, who sat down Tuesday with four Republican senators while in the presence (if not exactly the company) of the media. Matt Shuham reported on the moment for Talking Points Memo.

Speaking off-handedly about the prospects for the Trumpcare bill still in limbo in the Senate, Trump tipped his hand on his confidence in the outcome without realizing it, or maybe just without caring one way or another.

“This will be great if we get it done, and if we don’t get it done, it’s just going to be something that we’re not going to like and that’s OK and I understand that very well,” the president* said. “But I think we have a chance to do something very, very important for the public. Very, very important for the people of our country that we love.”

Note the relatively few important words in all of that, the words that matter: “if we don’t get it done ... that’s OK ...” Implicit in those eight words is at least a rhetorical expectation of failure, an embrace of the risk, and maybe even the likelihood, that things will not go as planned.

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That was one of Tuesday’s little big reveals on the future of the bill now known as the Better Care Reconciliation Act (apparently the second name for the Trump bill). The other one was when Senate Majority Leader Mitch McConnell pushed back the planned Senate vote on the bill until after the July 4 recess. “I had hoped, as you know, that we could have gotten to the floor this week, but we’re not quite there,” he told reporters. “But I think we’ve got a really good chance of getting there, it’ll just take us a little bit longer.”

That statement from the poster-boy senator for Obamacare repeal seemed to stir a chain reaction. Talking Points Memo reported that, not long after McConnell’s postponement of the planned Senate vote, three GOP senators — Shelley Moore Capito of West Virginia, Rob Portman of Ohio and Jerry Moran of Kansas — tweeted or released statements announcing their decision not to back the Trumpcare bill.

Capito, very popular in her home state, had the response that was the most rooted in practicality, the constituent-driven practicality of what works for the people who elected her.

“I recognize that many West Virginians rely on health coverage and access to substance abuse treatment because of my state’s decision to expand coverage through Medicaid. I have studied the draft legislation and CBO analysis to understand its impact on West Virginians,” she said in a joint statement with Portman. “As drafted, this bill will not ensure access to affordable health care in West Virginia, does not do enough to combat the opioid epidemic that is devastating my state, cuts traditional Medicaid too deeply and harms rural health care providers.”

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MAYBE THE president* knew what was coming from Capito and the others, maybe not. If he did know, maybe he felt he could ignore it. What he couldn’t ignore, of course, was the letter that landed the day before, the letter to McConnell and Senate Minority Leader Chuck Schumer direct from Dr. James Madara, executive vice president and CEO of the American Medical Association.

It couldn’t be more of a disaster for Trumpcare. “Medicine has long operated under the precept of Primum non nocere, or 'first, do no harm.’ The draft legislation violates that standard on many levels,” Madara wrote.

He continued: “Though we await additional analysis of the proposal, it seems highly likely that a combination of smaller subsidies resulting from lower benchmarks and the increased likelihood of waivers of important protections such as required benefits, actuarial value standards, and out of pocket spending limits will expose low and middle income patients to higher costs and greater difficulty in affording care.”

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Madara said the organization “continue[s] to oppose Congressionally-mandated restrictions on where lower income women (and men) may receive otherwise covered health care services – in this case the prohibition on individuals using their Medicaid coverage at clinics operated by Planned Parenthood. These provisions violate longstanding AMA policy on patients’ freedom to choose their providers and physicians’ freedom to practice in the setting of their choice.”

“We do appreciate the inclusion of several provisions designed to bring short term stability to the individual market, including the extension of cost sharing reductions payments. We urge, however, that these provisions serve as the basis of Senate efforts to improve the ACA and ensure that quality, affordable health insurance coverage is within reach of all Americans.”

Trump, the political object of serial two-by-fours to the head over the preceding 24 hours, thus came to the realization that “if we don’t get it done ... that’s OK ...” — a statement that effectively gives any senator that wants to back away from the bill the cover to do so without much penalty. Capito’s clear-as-glass opposition was based entirely on the needs of her fellow West Virginians; it was pothole politics played (and played well) on the national stage. If any rank-and-file Republicans need cover for the vote to come, she’s just given them plenty. So has the leadership of the AMA. And House Trump knows it.

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SO DOES MITCH McConnell. That explains the generally anodyne, perversely upbeat language in his scrum with reporters. But McConnell looks at least a little further down the road than most senators in the public eye. He’s not one for playing the long game, but he is capable of the longer game, looking for leverage no one else can see.

People have asked repeatedly how the Republicans could credibly advance such a willfully monstrous piece of legislation as the Trumpcare bill, which would eviscerate Medicare, remove pre-existing conditions as a coverage threshold, and balloon the health-care premiums for Americans in no position to pay them.

Leave it to Joshua Guess, my colleague at Swamp, to offer a provocative idea on June 24: Maybe McConnell isn’t serious.

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Guess writes: “The one read that no one seems to have on this situation is also the one I think is the most obvious: McConnell doesn't actually want the bill to pass. His mistake was in believing the base cared more than it does about ACA repeal and making new legislation a priority as a result. Everything going forward flows from that one wrong assumption. 


“What I believe he's really doing is deliberately crafting a bill he knows won't get the support of the necessary 50 GOP senators. By choosing to include provisions and language he knows will peel off certain votes, McConnell creates a liminal space where he believes blame can be targeted rather than directed at the party in general.

“As of right now, at least four GOP senators are publicly against passing the new legislation. If McConnell changes it to suit them, it will peel off several on the other end of the spectrum. This is the one central weakness of the congressional GOP. Finding a middle ground between the extreme right and the moderates is an increasingly narrow ledge to walk.”


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WE'RE PROMISED the climax of this drama sometime after the July 4th recess. By that time, McConnell says, he’ll have time to go back to other senators and wheedle and threaten and cajole ... and not coincidentally make changes in the bill that might make it more palatable. Changes that will, to one degree or another, make it more and more like Obamacare, the system they are sworn to destroy.

But it’s already too late. This iteration of Trumpcare is a variation of the one that died the death back in April; its prospects for survival shouldn't be any more likely than its predecessor. Also, the opposition is louder, it’s more grounded than it was before, and it’s wider now, with more opponents of Trumpcare emerging in red states all the time.

Consider the inescapable drumbeats: Not one state supports the Republican health-care bill as it stands, according to reporting and multi-poll calculations by The New York Times. “We found that Republicans have produced a rare unity among red and blue states: opposition to the A.H.C.A.,” The Times reported, using the old four-letter shorthand for the Trump bill's original name.

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Add to that the sporadic fury of off-the-chain citizens at town halls; the disappointing previous scores from the nonpartisan Congressional Budget Office (which estimated that up to 22 million Americans could lose their health care under Trumpcare); and the generally favorable marks Obamacare has gained in its seven years of uptime.

The end results? An administration eager to define itself by undoing what its predecessor did, rather that charting its own affirmative legacy, by using a program's best attributes in order to build something better.

A party foolishly willing to die on this anti-populist hill, despite the best advice of many within that party (never mind the approaching midterm-year realities).

And a president* who’s not exactly confident of the future of this bill, and an opposition that's just as certain the bill has no future at all.

Image credits: Trump: Kevin Lamarque/Reuters. McConnell: Associated Press. Swamp logo: © 2017 Jerrick Ventures LLC. Trumpcare supporters map: ©2017 The New York Times. Congressional Budget Office logo: © 2017 CBO.

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