Upcoming GOP Reform Package is Just the Start

Up until now, the debate over the repeal and replace of the Affordable Care Act has been limited to the reading of tea leaves and, at best, educated guesses. We’re about to get some meaningful data. Earlier this month, House Speaker Paul Ryan promised that Republicans in the House would unveil their health care reform legislation after the mid-February Congressional break. And, in fact, details of the GOP leadership’s Obamacare replacement plan leaked today. (More on that, below).

The introduction of this GOP health care reform proposal is significant, but hardly as earth shattering as you might think based on the news coverage over the leak, let alone the attention the official unveiling will generate. Nor is this proposal necessarily indicative reflective of whats going to emerge from Congress at the end of this process. Think of it as allowing educated guesses to be a bit more educated. That’s important, but it determines nothing.

If you’re interested in what the 106-page document leaked today shows, Sarah Kliff of Vox.com has an excellent analysis. She writes that “In broad strokes, the draft bill hews closely to ideas outlined by House Speaker Paul Ryan and Health and Human Services Secretary Tom Price.” However, she does identify one “important shift” from earlier GOP proposals: “This bill … has more generous financial support for those who buy their own plans … and lower penalties for Americans who do not maintain continuous insurance coverage.”

Of course, the first question to ask is whether the leaked document is legitimate. The answer appears to be yes. There’s no bombshell that would suggest it’s only a trial balloon. It hews closely to the long-espoused reforms put forward by Republicans supporting high-risk pools, promoting HSAs and permitting health insurers to sell across state lines. Let’s assume, then, what we’re seeing today is exactly what Speaker Ryan will unveil next week. Does it matter?

Yes, but not much.

Changing America’s health care system will take time, regardless of how many politicians tell you otherwise. There are a lot of reasons why. Here’s just three:

  1. Republicans can’t agree on what they want to do. Just in the House of Representatives there a numerous factions each looking for a different outcome. The (very) conservative Freedom Caucus wants to repeal the entire ACA now and deal with a replacement later (if ever). Establishment members want to work out the replacement plan first and then simultaneously repeal and replace the ACA after a long transition period. Some of the two dozen members who represent districts that went for Hillary Clinton in the recent presidential election (and, I suspect, a percentage of those who endured raucous town hall meetings this week) seem more intent on repairing the ACA as opposed to blowing it up. Meanwhile, Republicans in the Senate can’t agree on what should follow the Affordable Care Act either. Many Senators, however, seem certain they don’t like the direction the House is taking. In short, consensus among Republicans is a long way off.
  2. Republicans need Democrats to replace the ACA. Even if Republicans reach a consensus on health care reform, they still need to bring along some Democrats to get the job done. Yes, heavy damage can be inflicted on the ACA through changes to the federal budget that require a simple majority of lawmakers in each chamber to pass. Regulations and executive orders can tear down more of it. Replacing the Affordable Care Act, however, will require at least 60 votes in the Senate (unless Republicans take the highly unlikely step of ending filibusters). With only 52 Republican Senators that means at least eight Democrats have to vote for the replacement legislation. And if Republicans factions in the House get too entrenched, the House Leadership may need some Democratic votes in that chamber to get anything passed. All of which means a lot of negotiating before there’s any hope of getting a new health care reform bill on President Donald Trump’s desk..
  3. The stakes are high–really, really high. As I’ve written previously, if Republicans get health care reform wrong they could destroy the individual health insurance marketplace. And I mean destroy. In fact, it may be too late to save the individual market (a possibility I’ll have another post on soon). Yet the GOP has been promising their base to nuke the Affordable Care Act and replace it with something better since before it was passed. Republicans need to act, but in a way that doesn’t leave their party explaining to voters why the demise of individual coverage is not Republicans’ fault.

Don’t get me wrong. That the GOP House leadership is introducing health care reform legislation is a meaningful milestone along the path to a post-Obama American health care system. If Secretary Price and President Trump sign-on to the bill, it will be a “big league” milestone. At the end of the day, however, it’s a milestone, not the finish line; just the first steps in what will be a long slog through numerous committees, endless public posturing, lobbying by interest groups, tumultuous public demonstrations, and intense negotiation. What Republicans are putting forward now may bear only a passing resemblance to what we get at slog’s end.

Please check out my health care reform magazine on Flipboard for constantly updated, curated articles.

No One Defends the Status Quo. Nonetheless …

Health care reform is not for the weak willed. Just ask President Barack Obama. As Congress continues to draft legislation the President is expending his political capital to mobilize supporters of his reform package while at the same time seeking to soften the opposition. As tough as the task lawmakers face, President Obama’s is in many ways the more challenging.

Consider President Obama’s appearance today before the American Medical Association. According to the Associated Press, when he sympathized with the doctors on the need to address malpractice reform he was cheered. When he told them he did not oppose capping malpractice judgements as the way of accomplishing this, some booed. That the President brought up malpractice at all was enough to mobilize trial lawyers. The president of their primary lobbying organization, the American Association for Justice, issued a statement denying that defensive medicine leads to higher health costs, according to the Associated Press.

Then of course there’s the opposition from the insurance industry and others concerning the creation of a government-run health plan to compete with private carriers. Yes, compromises are being put forward to find common ground on this issue. Meanwhile, however,  there’s former-Governor Mitt Romney’s claiming on ABC’s “This Week” Sunday declaring that public plans are “a Trojan horse … a way of getting government into the insurance business so they can take over health care.”

Or take the Republican attack on the Administration for creating a working group to study the effectiveness of various medical treatments. Representative Tom Price, a former surgeon, accused the President of “seeking a government takeover’ of health care.” The committee, he claimed would turn into rationing boards that would instruct doctors what services they could — and could not — provide their patients.

In a similar vein, Senate Minority Leader Mitch McConnell, Senate Minority Whip Jon Kyle and other GOP Senators introduced “The Preserving Access to Targeted, Individualized, and Effective New Treatments and Services (PATIENTS) Act. The legislation’s sponsors claim it is targeted at “comparative effectiveness research” which they claim is “commonly used in ‘socialized health care systems,” according to The Hill’s Blog. To its advocates, comparative effectiveness research holds the promise of eliminating much of the $700 billion in unnecessary medical spending incurred each year. It would also go a long way toward eliminating the disparity in spending profiled by Dr. Atul Gawande in his much discussed New Yorker article. Opponents do not address the difficulty in making politically free determination of what treatment is effective or not. Instead they attack it as empowering the government to determin who lives and who does not, even though current instances of comparative effectiveness programs in the United States are highly regarded by doctors, patients and others.

No one is defending the status quo. Not surprising since most people believe it is seriously broken. President Obama has rightfully framed the health care reform debate as an integral part of his economic recovery efforts. The reality is that American businesses are hamstrung by an often dysfunctional system. It’s equally true that hundreds of billions of dollars are wasted each year on defensive medicine, ineffective treatment and overpriced prescriptions.

The critical political puzzle facing President Obama is whether he can marshal the votes necessary to force through health care reform that causes pain to so many interests while improving on the status quo. He has some advantages other presidents have not shared. There is widespread agreement the status quo is unacceptable. He is extremely popular. His party holds significant majorities in both the House and Senate.

And did I mention the widespread agreement that the status quo is unacceptable? Because it is worth repeating. Opponents to reform have an advantage. They can zero in on one or two items they dislike knowing others will be attacking the package in other weak spots. To prevent the death of reform by a thousand cuts the Administration will need to fend off all of these attacks. Not an easy task. Among other tactics, it will require developing compromises that address opponents’ reasonable concerns without watering down the entire package so much it fails to improve on the current system.

That’s why health care reform is not for the weak willed.