Analysis: GOP Failure To Replace The Health Law Was Years In The Making

By Julie Rovner July 28, 2017

This story was originally published on July 18.

After a week of high drama, culminating in a one-vote loss for a last-ditch bill, Senate Republicans conceded defeat early Friday morning in their seven-year push to “repeal and replace” the Affordable Care Act.

The failure, at least for now, breaks one of the key promises Republicans have made to their voters since 2010, when the ACA first became law.

“This has been a very challenging experience for all of us,” Senate Majority Leader Mitch McConnell (R-Ky.) told reporters Tuesday afternoon. “It’s pretty clear that there are not 50 Republicans at the moment to vote for a replacement for Obamacare.”

Monday night’s declaration of opposition by conservative Sens. Mike Lee (R-Utah) and Jerry Moran (R-Kan.) effectively scotched even the chance to start debate on the version of a bill unveiled July 13.

McConnell added that the Senate would vote early the following week on a plan, originally approved in 2015 and vetoed by President Barack Obama, that would repeal parts of the health law. That approach would delay the effective date for two years to give lawmakers time to come up with a replacement.

However, the opposition of moderate Sens. Susan Collins (R-Maine), Shelley Moore Capito (R-W.Va.) and Lisa Murkowski (R-Alaska) ensured that vote would fail, too.

“To just say ‘repeal and trust us, we’re going to fix it in a couple of years,’ that’s not going to provide comfort to the anxiety a lot of Alaskan families are feeling right now,” Murkowski told reporters.

In retrospect, Republicans’ inability to overhaul the health law should not come as much of a surprise. Here are some of the reasons:

1. It’s hard to take things away from people.

Once launched, federal programs that provide people with benefits they find important and valuable are very difficult to rescind. In the case of health care, people’s lives can be at stake. In the current debate, patients who feared what would happen to their health coverage made their concerns known — loudly — to lawmakers.

2. Republicans have long been divided on health care.

Republicans’ dirty little secret the past seven years is that the only thing they fundamentally agreed on when it comes to health care was the slogan “repeal and replace.” There’s a reason they failed to have a plan ready when Donald Trump was elected president — all efforts to reach a consensus had thus far failed.

“I did not come to Washington to hurt people,” said Capito in a statement. “I have serious concerns about how we continue to provide affordable care to those who have benefited from West Virginia’s decision to expand Medicaid.”

But the more conservative members, notably Sen. Rand Paul (R-Ky.), have other priorities. “All of us promised we would repeal Obamacare,” Paul told reporters Tuesday. “If you’re not willing to vote the way you voted in 2015, then you need to go back home and you need to explain to Republicans why you’re no longer for repealing Obamacare.”

3. Presidential leadership on hard issues is important.

President Trump has been all over the place in what he said he wanted from a health bill. It was his original insistence that “repeal and replace” happen simultaneously that moved Congress away from its 2015 strategy of repealing first and replacing later. He hosted a celebration in the White House Rose Garden when the House passed its bill, then subsequently called the measure “mean” during a strategy meeting with senators.

When it became clear Monday night that the Senate effort was foundering, Trump tweeted: “Republicans should just REPEAL failing ObamaCare now & work on a new Healthcare Plan that will start from a clean slate.” But within hours he instead suggested, “As I have always said, let ObamaCare fail and then come together and do a great healthcare plan.”

The president “gave them an impossible assignment with his promises (more, better, cheaper for all) and neither policy nor bully pulpit help at crunch time,” said Len Nichols, a professor of health policy at George Mason University. “And now he’ll blame them for failing.”

Added Thomas Miller, of the conservative American Enterprise Institute: “We now have a randomized clinical trial that proves one cannot lead and govern via Twitter.”

4. Health care is complicated. Really.

Health care has not traditionally been a major voting issue for Republicans, and thus it has been a low priority — compared with issues like taxes and trade — for the officials they elect.

Adding to the complexity is that the Republicans’ bench is nowhere near as deep as the Democrats’ when it comes to health policy expertise. Democrats have toiled on these issues for years. Even before the Affordable Care Act, many had served in Congress for decades and learned from the mistakes that were made on efforts like the failed health bill under President Bill Clinton.

5. Some parts of the ACA really are popular, even among Republicans.

The requirement for most people to have insurance or else pay a fine — the individual mandate — has consistently been unpopular among voters of all political stripes. But many other major provisions of the health law, such as guaranteeing coverage for people with preexisting conditions, remain broadly popular.

In fact, in recent months, the Affordable Care Act has been growing in popularity. Most polls show it’s more than twice as popular as GOP efforts to overhaul it.

“Republicans have to admit that some of the things in the ACA we actually liked,” said Murkowski.

That left a huge gap between Republicans who wanted to maintain the popular benefits and those who wanted to repeal the law entirely. A gap that, so far, Republicans have been unable to bridge.

Rachel Bluth contributed to this story.

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10 things to know about the Veterans Choice Program

The Veterans Choice Program (VCP) is a benefit that allows eligible Veterans to receive health care from a community provider rather than waiting for a VA appointment or traveling to a VA facility.

1. Am I eligible for the Veterans Choice Program?

To be eligible for the program, you must be enrolled in VA health care and must also meet at least one of the following criteria:

• You are told by your local VA medical facility that you will need to wait more than 30 days for an appointment.
• You residence is more than a 40 mile driving distance from the closest VA medical facility with a full time primary care physician.
• You need to travel by air, boat, or ferry to the VA medical facility closet to your house.
• You face an unusual or excessive burden in traveling to the closest VA medical facility based on a geographic challenge, environmental factor, medical condition, or other specific clinical decisions. Staff at your local VA medical facility will work with you to determine if you are eligible for any of these reasons.
• You reside in a State or a United States Territory without a full-service VA medical facility that provides hospital care, emergency services and surgical care, and reside more than 20 miles from such a VA medical facility. Note: This criterion applies to Veterans residing in Alaska, Hawaii, New Hampshire, Guam, American Samoa, Commonwealth of the Northern Mariana Islands, and the U.S. Virgin Islands. Also note that some Veterans in New Hampshire reside within 20 miles of White River Junction VAMC and are therefore not eligible for the Veterans Choice Program.

2. What if I think I am eligible?

• Call the VCP Call Center at 866-606-8198 or visit the Veterans Choice Program website to verify eligibility and set up an appointment here.

3. Can I call my non-VA doctor to make an appointment?

• No, please call the VCP call center at 866-606-8198 to verify eligibility and set up an appointment.

4. How is the 40 mile calculation determined?

• This calculation is based on the driving distance from your permanent residence (or active temporary address) to the closest VA facility, including Community-Based Outpatient Clinics and VA Medical Centers. You are eligible if you live more than 40 miles driving distance from the closest medical facility that has a full-time primary care physician.

5. If I am eligible for the Veterans Choice Program, can I receive Beneficiary Travel for travel to appointments with a VCP provider?

• Yes, the Choice Act does provide funding to pay for travel to VCP providers for Veterans who are eligible for Beneficiary Travel. However, it did not provide any new Beneficiary Travel eligibility.

6. If I didn’t get my Choice Card or I lost my Choice Card, what do I do?

• You do not need your Choice Card to access the VCP. If you didn’t receive a Choice Card or lost your Choice Card, simply call 866-606-8198 to find out if you are eligible and to make an appointment.

7. How do I get my prescription filled if I use the Veterans Choice Program?

• The community provider you see through the VCP can issue a prescription for up to a 14 day supply of a national formulary drug. You may have the 14 day supply filled at any non-VA pharmacy of your choosing.
• Prescriptions can be reimbursed through the Business Office/Non-VA Care Coordination Office at VA facilities. This reimbursement may take 30-45 days to process, and requires a copy of the prescription and the original receipt. Veterans cannot be reimbursed at the VA Pharmacy.
• For prescriptions needed past 14 days, please follow standard procedures to fill a prescription at the VA pharmacy.

8. If I use the Veterans Choice Program, does that affect my VA health care?

• No, not at all. You do not have to choose between the two. The VCP is here to make it easier to access the care you need. VA is building a high-performing integrated health care network to deliver the best of VA and the community. This integrated network will give Veterans more choices to access care and ensure care is delivered where and when you need it.

9. What is my responsibility for co-payments to my other insurance?

• Nothing. VA is now the primary coordinator of benefits for VCP, so you are only responsible for your VA copayment.
• Your VA copayment will be determined by VA after the care is provided. VA copayments will be billed by VA after the appointment.

10. How does the new VCP extension law affect me?

• Public Law 115-26, enacted April 19, 2017, made three key changes to help improve the VCP. The law removed the expiration date for the program, made VA primary coordinator of benefits for services provided to you, and it removed barriers with sharing necessary health information with community providers.

More Information

• Please refer to the Veterans Choice Program website for more information about the program, its benefits, and eligibility criteria here.
• Providers interested in participating must establish a contract with one of the contractors, Health Net Federal, or TriWest Healthcare Alliance. For more information, about how to participate please visit Veterans Choice Program website for providers.
  
  

-- VAntage Point Contributors provide insight and perspective on a wide range of Veterans issues. If you'd like to contribute a story to VAntage Point, learn how you can submit a guest blog at http://www.blogs.va.gov/VAntage/how-to-submit-a-guest-post/

http://www.blogs.va.gov/VAntage/39882/10-things-know-veterans-choice-program/

Seema Verma Runs Medicaid. Her Husband’s Practice Won’t Accept It.

By Phil Galewitz July 27, 2017

Members of the Trump administration and Republicans on Capitol Hill repeatedly say the country’s Medicaid system is “broken” and enrollees struggle to get care because many doctors refuse that coverage.

The top U.S. official overseeing Medicaid — Seema Verma — doesn’t have to look far to find an example. Her husband, Dr. Sanjay Mishra, is one of them.

Mishra is a child psychiatrist in Carmel, Ind., and a partner and medical director of Indiana Health Group, a large medical practice specializing in mental health. That group doesn’t accept Medicaid.

“It’s sadly ironic, but given what I know … I am not one bit surprised,” said Dr. J. Wesley Boyd, associate professor of psychiatry at Harvard Medical School, who co-authored a study this year on the struggles faced by children enrolled in Medicaid as they seek care.

Verma is administrator of the Centers for Medicare & Medicaid Services and a former consultant who helped design Indiana’s Medicaid program.

Jane Norris, a CMS spokesman, said Verma’s husband does not accept Medicaid because that “helps avoid any further conflict of interest or complication of her recusal obligations.”

A spokesman for Indiana Medicaid said Mishra stopped participating in the program in 2007, when Verma began consulting with the state.

Neither Mishra nor a spokesman for his medical group returned calls for comment.

Mishra is one of many specialists nationwide, particularly mental health professionals, who don’t accept Medicaid. Most say the program’s reimbursements are too low.

Matthew Brooks, CEO of the Indiana Council of Community Mental Health Centers, would not comment on Mishra. But he said that in Indiana patients’ ability to get care “is negatively impacted by the limited number of providers, especially in rural areas.”

Dr. James Bien, a pediatrician in West Lafayette, Ind., said he often finds it hard to refer patients — both those who have private insurance and those with Medicaid — to psychiatrists because there is a shortage of such specialists. “It’s really tough. You sort of feel helpless sometimes,” he said. “It’s an even tougher challenge for kids on Medicaid.”

Recently, when looking for help for a teenage patient who attempted suicide, Bien had to refer the boy to a doctor nearly 70 miles away in Indianapolis.

In another case, Bien said, he looked as far as Chicago to find help for a teenage boy with severe depression who was acting aggressively toward his parents and struggling in school. He eventually found a child psychiatrist willing to take this patient more than an hour’s drive away. The family still had to wait weeks for an appointment.

Many families who need a child psychiatrist face long waitlists. And this problem starts with the supply issue. According to the American Academy of Child and Adolescent Psychiatry, there are about 8,300 practicing child and adolescent psychiatrists in the United States — and more than 15 million youths in need of one.

That limited access can have far-reaching consequences. The longer a psychiatric illness or family dysfunction continues, the more difficult it is for the child to succeed. Untreated problems can worsen and lead to difficulties in school.

The challenge is further complicated by the fact that fewer than half of child psychiatrists take Medicaid, said Dr. Peter Metz, a child psychiatrist and professor at the University of Massachusetts Medical School. “It’s a big issue,” he added.

In a 2011 New England Journal of Medicine study, researchers from University of Pennsylvania posing as mothers of children seeking psychiatry appointments were denied 83 percent of the time when they said they had Medicaid and 49 percent when they said they had private insurance.

Boyd and colleagues identified the same problem in their study. Researchers posing as the parent of a depressed 12-year-old who had private insurance or would pay out-of-pocket got an appointment with a psychiatrist or pediatrician 37 percent of the time. When the researchers making the call said they had Medicaid coverage, that figure dropped to 22 percent, the study found.

Metz said there’s a simple reason why Mishra and many child psychiatrists don’t take Medicaid. “It’s financial, it’s because of the low reimbursement rates that Medicaid pays,” he said. Although rates vary by states, Medicaid often pays the specialists less than half the fee they could collect using private insurance or charging a patient directly, according to several psychiatrists.

Paul Gionfriddo, CEO of Mental Health America, an advocacy group, said a cut in federal Medicaid funding would make it harder for states to increase reimbursement rates to providers and entice more of them to see enrollees.

“It would be better if Seema Verma’s husband were to accept Medicaid, not just for the appearance of supporting the program his wife oversees, but to increase access by one more provider,” he said.

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Shulkin to VFW: We want Veterans to get the right care at the right place

On Monday, July 24, Secretary of Veterans Affairs Dr. David J. Shulkin addressed an audience of VFW and Auxiliary members at the Veterans of Foreign War (VFW) 118^th National Convention in New Orleans.

In his remarks, Shulkin spoke on the five key priorities he has identified to transform VA. The first of those five priorities is to give Veterans greater choice.

“When I talk about greater choice, right now we have a system that I would call a rules-based system,” Shulkin said, highlighting how administrative rules, such as how far a Veteran lives from a VA, dictates whether that person can get care in their local community. “I believe we need a system that’s not based on rules, but is based on your clinical needs.”

 “We want that clinical flexibility to be able to allow Veterans to be able to get the right care at the right place,” Shulkin told the VFW convention attendees.

The secretary’s comments echoed an editorial that appeared earlier on Monday. Shulkin wrote in USA Today that community care, or private capacity, and VA’s internal capacity are not mutually exclusive.

“We are ramping up both simultaneously in order to meet the health care needs of the Veterans we are charged with serving,” he wrote.

VA is embarking on the largest transformation and modernization effort in recent history. Secretary Shulkin recently established the VA Office of Accountability and Whistleblower Protection and announced that the VA will dispose of 430 vacant buildings in 24 months. In June, the President signed into law the VA Accountability and Whistleblower Protection Act and Secretary Shulkin announced that the VA will adopt a joint electronic health record system integrated across all Department of Defense and VA components.

VFW is a nonprofit Veterans service organization comprised of eligible Veterans and military service members from the active, guard and reserve forces. Today, membership stands at nearly 1.7 million members of the VFW and its Auxiliary

http://www.blogs.va.gov/VAntage/39864/shulkin-to-vfw-we-want-veterans-to-get-the-right-care-at-the-right-place/

Leap Of Faith: Will Health Care Ministries Cover Your Costs?

By Emily Bazar

July 28, 2017

Martin Estacio was shelling out $800 per month for a health plan that didn’t fit his two-state lifestyle.

The retired San Bernardino firefighter lives between Oklahoma and California. But his health insurance policy, purchased in Oklahoma, didn’t cover non-emergency care outside the state.

So Estacio dropped his plan this month and took a leap of faith. He joined Christian Healthcare Ministries (CHM), an alternative to health insurance that offers a religious approach to covering medical bills.

Health care ministries such as CHM are essentially cost-sharing programs. Members’ monthly fees are applied directly to other members’ medical bills, no matter where they live in the U.S. Members also pray for each other, and often send notes of support and encouragement.

“What led me to look into it was financial,” says Estacio, 58. “When I started to realize it’s based on biblical principles where you help your brother out, that’s what really clinched me.”

A health care sharing ministry is primarily a “community of faith,” says Michael Gardner, spokesman for Christian Care Ministry, which operates the Medi-Shareprogram. Medi-Share has roughly 300,000 members as of June, he says.

But let’s be clear: Christian health care ministries are not insurance. You must attend church regularly. You must agree to abstain from certain behaviors, such as “sexual immorality” and drug abuse. Preventive care, routine prescriptions and mental health care may not be reimbursed. Forget about abortion. Coverage for your preexisting conditions will likely be limited — at least initially.

Estacio pays $150 per month for his membership, plus quarterly payments of about $30 that offer him a higher level of reimbursement.

He’s responsible for the first $500 on each medical incident before the ministry’s sharing kicks in, but only for allowed services. CHM’s list of non-covered services includes “psychological treatment,” medical supplies and equipment, immunizations, maintenance prescriptions and bills related to drug abuse.

“You have to try to live a good lifestyle,” Estacio says. “You can’t be drinking and smoking. It’s on you.”

Membership in health care sharing ministries has ballooned since passage of Obamacare, in part because the health law provides an exemption for members. If you belong to a qualified health care sharing ministry, you don’t have to pay the Obamacare tax penalty for not having insurance.

About 1 million Americans participate nationwide, according to the Alliance of Health Care Sharing Ministries. Texas has the most members; California places second.

There are more than 100 ministries across the U.S., though the vast majority are small Mennonite churches, says alliance President Dave Weldon, a doctor and former Florida congressman. The three largest ministries are CHM, Medi-Share and Samaritan Ministries International, he says.

All the ministries are Christian at this point, though Weldon says there’s an attempt to start a Jewish sharing ministry.

“It’s our Christian practice of how we bear one another’s burdens,” says James Lansberry, executive vice president of Samaritan Ministries, which has about 227,000 members nationwide.

Samaritan members, who share about $23 million a month, mail their monthly fees directly to other members facing medical bills, along with notes of support, Lansberry says.

Each ministry works differently, but you can generally expect to pay a monthly membership fee. You may be responsible for all of your own routine and preventive medical costs in addition to paying a set amount before reimbursements kick in.

“In effect, they become sort of like catastrophic programs,” Weldon says. “But that’s true for a lot of plans on the Obamacare exchanges as well.”

Unlike catastrophic insurance plans, there’s no contract with health care sharing ministries, he says. That means there’s no guarantee that your bills will be covered.

“However, most of them have always paid their members when they have medical bills,” Weldon says.

Because there’s no guarantee, and because the ministries limit coverage, Sabrina Corlette has two words for you: “Buyer beware.”

“Read the fine print,” says Corlette, research professor at Georgetown University’s Center on Health Insurance Reforms. “Make sure you truly understand what you’re getting with these plans.”

Coverage Caps And Covered Services

Some of these ministries put dollar limits on coverage, a practice that Obamacare ended for most commercial health plans.

“If you’re fairly young and fairly healthy, you may never face that,” says Janet Coffman, associate professor of health policy at University of California-San Francisco. But “some people have catastrophic illnesses that may cost millions of dollars.”

Most health care sharing ministries don’t cover preventive care such as mammograms, colonoscopies and birth control, and some don’t cover mental health care, addiction treatment and other services, Coffman says.

Since monthly fees are generally less than health insurance premiums, members can save money on those costs, says Medi-Share’s Gardner.

“Because it’s so much less expensive, I can be a good steward of my finances and set some money aside,” he says.

Preexisting Conditions

Health care sharing ministries aren’t required to cover preexisting conditions.

As a result, “a lot of these plans have waiting periods or limitations” on them, says Coffman.

You may have to wait one to three years — or longer — to be reimbursed for preexisting conditions. And you may face a limit on reimbursement.

Providers ‘Willing To Take Cash’

Medi-Share has a network of providers with which it has negotiated rates, though members are not limited to it, Gardner says.

Samaritan does not have such a network.

“Patients are treated by providers as cash pay,” Lansberry says. “Members make their own choice.”

In these cases, if you have a doctor you want to keep, would she be willing to see you as a cash customer?

“We’ve never had trouble with members losing their doctors,” Lansberry says. “Doctors are almost always willing to take cash.”

But remember: You may have to cover the entire cost of the bill and wait for reimbursement.

“Should you have to be hospitalized, could you afford it upfront?” Corlette asks.

The ministries encourage you to negotiate for lower prices with providers, though they usually go to the bargaining table for you when the bills are large.

Right To Appeal

Health care sharing ministries are not regulated by government agencies that oversee commercial health insurance.

If you don’t agree with how much you’re being reimbursed — or whether you’re being reimbursed at all — your only recourse will likely be an internal appeals process.

State regulatory agencies wouldn’t have any power to help you, says Janice Rocco, deputy insurance commissioner at the California Department of Insurance.

We “encourage people to obtain commercial health insurance, which they know they can count on if they have a serious health crisis in the future,” she says.

Estacio hasn’t had to request reimbursement from his health care ministry yet, and he has money set aside for health care expenses that wouldn’t be eligible for reimbursement.

But he’s not worried.

“I’m confident,” he says. “I have faith in it.”

Emily Bazar: ebazar@kff.org, @emilybazar

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Penalty for Refusing to Get Health Insurance Remains Intact

By THE ASSOCIATED PRESS

JULY 28, 2017, 4:54 A.M. E.D.T.

WASHINGTON — Opponents of President Barack Obama's health care law who wanted to get rid of the penalty people were assessed for not having health insurance will have to wait longer for relief after the Senate early Friday defeated the GOP's scaled-back version of legislation repealing the Affordable Care Act. .

One of the main reasons GOP lawmakers had given in their quest to overturn "Obamacare" was that they want to lower premiums for people who buy individual health insurance policies, particularly constituents who get no help from the law's tax credits. Some states are facing a second year of double-digit hikes.

"There is no doubt whatsoever that premiums in the individual insurance market would go up," said Larry Levitt of the nonpartisan Kaiser Family Foundation. "There is irony here in that the mantra from Republicans throughout this debate has been the need to lower premiums, but this step would do just the opposite."

Premiums would have gone up because insurers feared that without the penalty and the health law's underlying requirement to carry insurance, some healthy people would drop their coverage. That would have left insurers with a pool of sicker, costlier customers.

How big an increase?

An analysis last year from the nonpartisan Congressional Budget Office estimated an increase of roughly 20 percent, and Senate Minority Leader Charles Schumer of New York says the budget office has told his staff that estimate still stands.

The CBO estimated this week that about 16 million people would become uninsured if the coverage requirement is repealed. Without the penalty, healthier people and those juggling tight household budgets might decide to take a chance and drop coverage.

The penalty for going without coverage last year was the greater of $695 or 2.5 percent of household income, due when taxpayers file their returns. The amount is adjusted annually for inflation, so it would be higher this year if the penalty stays on the books. According to the latest IRS figures available, about 6.5 million households paid the penalty for tax year 2015, averaging about $470 each.

Repeal of the penalty was the centerpiece of the GOP's so-called "skinny repeal" bill, the last-ditch effort to get legislation through the Senate that failed in the early morning vote Friday. The bill would have left most of the ACA intact, striking only some of its most unpopular provisions. Senate Republicans say it wasn't meant to be a final product, but, instead, a maneuver to advance legislation so a House-Senate conference committee can rework it into a comprehensive package. Indeed, some senators fear the House would suddenly pass the measure and declare victory.

"I've told everybody this cannot be the final product," said Sen. Lindsey Graham, R-S.C.

"If you passed it as a stand-alone proposition it would destroy the insurance markets and we would own the failure of Obamacare," Graham added.

The health insurance industry opposed the provision.

Ten governors — five Republicans and five Democrats — have asked the Senate to drop the idea, warning it is "expected to accelerate health plans leaving the individual market, increase premiums, and result in fewer Americans having access to coverage." The governors want Congress to start over and try to come up with a bipartisan approach.

The unpopular penalty and coverage requirement were intended to nudge healthy people into the insurance market. They are modeled on an approach that Massachusetts passed in 2006 under former Republican Gov. Mitt Romney. The Massachusetts health overhaul had wide acceptance in that state, but the federal version under Democrat Barack Obama proved to be highly controversial.

Nonetheless, previous Republican health bills have recognized the importance of having some kind of penalty for people who don't maintain their coverage. Proposals have ranged from a surcharge on premiums to waiting periods. Something like that would likely be part of any final House-Senate legislation.

Those ideas are also unpopular with Americans. A recent AP-NORC poll found that 72 percent would oppose a six-month waiting period, and 67 percent would oppose a surcharge on people who had a break in coverage.

___

Associated Press writer Mary Clare Jalonick contributed to this report.

https://www.nytimes.com/aponline/2017/07/27/us/politics/ap-us-health-overhaul-insurance-penalty.html?utm_campaign=KHN%3A%20First%20Edition&utm_source=hs_email&utm_medium=email&utm_content=54732817&_hsenc=p2ANqtz-8hjhBFYK2rWdIlc9vXHBGyiEwEBj0LokLAunyYHmAMw7LBjkPxLlZTS-9Gnzx9LgpGjqSNfjt2VA06xmiHBb_b8hsVDA&_hsmi=54732817

5 Takeaways From the Failed Senate Effort to Repeal Obamacare

By THOMAS KAPLAN

JULY 28, 2017

WASHINGTON — The Republican Party’s seven-year dream of dismantling the Affordable Care Act came to what seemed like a climactic end early Friday, punctured by the Senate’s vote to reject a last-ditch proposal to repeal a few parts of the health law.

With the vote on a “skinny” repeal bill, Republican leaders were trying what amounted to a legislative Hail Mary pass. But they could afford to lose only two party members, and three Republicans voted no: Susan Collins of Maine, Lisa Murkowski of Alaska and John McCain of Arizona.

Here are some of the key lessons from the evening:

The process matters.

Republicans grumbled about the secretive manner in which the majority leader, Senator Mitch McConnell of Kentucky, put together his repeal bill. There were no public hearings or formal bill-drafting sessions, and Republicans used a fast-track procedure meant for budget matters as they tried to enact complex health policy and avoid a filibuster.

Mr. McCain was an outspoken critic. In June, asked his comfort level with the process, he cut off a reporter. “None,” he said.

The final hours of the repeal effort seemed worse than ever: Republican leaders unveiled their bill and then expected their members to vote for it hours later, and in the middle of the night, no less.

President Trump was no help.

Without the election of Mr. Trump last year, putting a Republican in the White House, the repeal effort would have been an academic exercise, ending in a certain veto. But Mr. Trump did not prove persuasive in recent days.

In public, he did not show much fluency in the basics of health policy, let alone the ability to persuade Republicans on complicated issues like the growth rate of Medicaid payments. And he did himself no favors by changing his demands about exactly what he wanted the Senate to do.

Bullying isn’t effective.

After Ms. Murkowski voted against beginning debate on health care, Mr. Trump went after her on Twitter. It was not a fair fight: He has more than 34 million followers, and she has about 99,000.

Mr. Trump also directed the interior secretary, Ryan Zinke, to call Ms. Murkowski and remind her of the Alaska issues controlled by his department.

It wasn’t a subtle move. But this time, Ms. Murkowski held the whip hand: She is chairwoman not only of the Senate Energy and Natural Resources Committee, which has jurisdiction over the Interior Department, but also of the appropriations subcommittee that funds it. Ms. Murkowski voted no.

The abortion debate didn’t make things easier.

The politically difficult task of coming up with sweeping health legislation was made more challenging by differing views of abortion, an issue that was at the periphery of the Republican efforts but was a persistent complication.

The slimmed-down bill, like the comprehensive Senate legislation before it, would have cut off federal funds to Planned Parenthood for one year, a major demand of conservatives and of anti-abortion groups like the Susan B. Anthony List. Ms. Collins and Ms. Murkowski both opposed that provision. Just hours before the vote, Ms. Collins said the bill “unfairly singles out Planned Parenthood.”

A slim majority has its limits.

Senate leaders ultimately could not overcome a fundamental problem: Ms. Collins has a very different view of health policy than, say, Senator Rand Paul of Kentucky.

Such divergent views might not be a problem if Republicans held a big majority in the Senate. But as Republicans hold only 52 seats, their leaders have had to worry about pleasing both the most conservative and the most moderate members. In an otherwise disappointing year for the party, Democrats won Senate seats in Illinois and New Hampshire in 2016, and their freshman senators, Tammy Duckworth of Illinois and Maggie Hassan of New Hampshire, made all the difference.

https://www.nytimes.com/2017/07/28/us/politics/senate-health-care-highlights-mccain-murkowski.html?utm_campaign=KHN%3A%20First%20Edition&utm_source=hs_email&utm_medium=email&utm_content=54732817&_hsenc=p2ANqtz-9bYZbi1MwaDJctNwKdZYFGDqXq2gENMBcvlY1sDcTWXTt1W54Ljkts9NueURahInMgK3xqTCoxFMCo2WXLzURSXMVCAg&_hsmi=54732817