Blog No. 131. The Healthcare Dilemmas

The healthcare bill drafted by House Republicans was finally unveiled and is now making its way through House committees at an accelerated pace. It is doing so without benefit of estimates from the non-partisan Congressional Budget Office as to cost and the number of persons who will be covered. The White House has attempted to minimize this deficiency–and to inoculate itself against the CBO report on the ground that CBO estimates are sometimes wrong. Indeed they are, but if the estimates here are discouraging, as is likely, it will be up to the White House and Republicans on Capitol Hill to provide alternative estimates from a credible source.

Given the current pace, one is reminded of the ancient proverb that haste makes waste. Indeed, Republican Senator Tom Cotton echoed that sentiment in a plaintive tweet:

House health-care bill can’t pass Senate w/o major changes. To my friends in House: pause, start over. Get it right, don’t get it fast.

On the other hand, it is not clear that a more deliberate pace would yield consensus or a sound result. The Republicans, having campaigned for years on the mantra of “repeal and replace,” now find themselves confronted with the challenge of actually doing so. At opposite ends of Pennsylvania Avenue, President Trump and Speaker Ryan project images of sunny optimism. Whether those images can be sustained remains to be seen. The last blog quoted George Will as having written that OMB Director Mick Mulvaney had been presented with a Rubik’s Cube of programmatic demands and fiscal constraints. The replacement of Obamacare, however, appears to constitute a Rubik’s Cube all on its own.

There has been extensive coverage of the Republican bill and I do not intend to burden readers of by getting deeply into the weeds of the proposed bill. The labor of such scrutiny may best be deferred until there is more likelihood of a bill that will actually be approved by both the House and Senate and sent to the president for signature. At this point, there appear to be major obstacles to that occurring. As widely reported, Democrats might be open to some alteration of Obamacare, but are unified in their opposition to anything in the nature of repeal and replace. Republicans, on the other hand are conspicuously divided in their support of the bill, and it would take only 21 defections in the House or 2 in the Senate to cause the bill to fail.  Nevertheless, it is worth noting briefly a few fundamental contradictions.

— From the standpoint of the Freedom Caucus in the House, and other conservative Republicans, the bill is objectionable because the refundable tax credits made available to purchase insurance amount to a new entitlement program. They have a point, but that train has left the station. There now appears to be a broad political consensus among the public for government support of individual healthcare and whatever form the support takes, it is likely to be seen as an “entitlement.” It would be theoretically possible simply to repeal Obamacare without purporting to replace it with anything, but that would likely lead to a political revolt of major proportions.  Moderate Republicans, on the other hand, are concerned as to whether the scale of the proposed tax credits may be insufficient to keep millions of people from losing the insurance coverage they now enjoy under Obama care. (The CBO estimate will be available on Monday, but estimate by outside organizations have suggested that 19 million or more individuals may lose coverage.)

— A similar divide is found with respect to Medicaid. The bill would freeze funding for the 31 states that expanded Medicaid. Conservatives seek a more drastic curtailment of Medicaid while moderates (including many Republican Governors in expansion states) find even the current proposal to be unduly harsh. President Trump has reportedly suggested that the “sunset” for the Medicaid expansion could be advanced, but that would heighten the risk of losing moderates.

— As previously noted the cost of the Republican proposal also awaits the CBO estimate, but it will reflect not only the refundable tax cuts but the cost of eliminating various taxes on the wealthy. Justifying such tax relief for the 1% should challenge the most talented spin-meisters. Beyond that the effects on the deficit and the debt are likely to be significant.

— Finally, the bill contains a provision barring funding of Planned Parenthood. This provision is quite extraneous to the reform of Obamacare, but it is something near and dear to many Republican hearts. It is also a mistake, even for passionate opponents of abortion. As explained by Michael Specter in the New Yorker, the likely result would be the opposite of what is hoped for. “Planned Parenthood Means Fewer Abortions.”

President Trump and his staff have weighed in vigorously on behalf of the Republican bill, arranging numerous meeting with members of Congress. Setting aside the flawed product he is attempting to sell, he deserves credit for doing so. It is the kind of leadership on Capitol Hill that was too often lacking from President Obama. It is unfortunate that his efforts are not being expended in a worthier cause.

Despite Trump’s efforts, it seems unlikely that the bill will reach his desk in anything like its present form. But perhaps failure of the bill is not the worst outcome. As David Brooks put it:

This thing probably won’t pass, but even if it passes it will probably lead to immense pain and disruption. That will discredit market-based social reform, cost the Republicans their congressional majorities and end what’s left of the Reagan-era party.


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In Blog No. 129, I advised that, with a one minute video, I had entered a contest to be a ring bearer for presentation of World Series rings to the Chicago Cubs team on April 12. I now regret to advise that I was not selected. Consulting President Trump about this, he advised me to claim that the selection process had been rigged and to demand an investigation. I do not plan to do that.  A lifetime as a Cubs fan has schooled me in the ways of accepting disappointment with spirits undiminished.

3 thoughts on “Blog No. 131. The Healthcare Dilemmas

  • Haste makes waste!??? They’ve had seven-plus years to put together a meaningful alternative to the ACA and have failed miserably. The only positive claim they can make is that their proposed changes take only 100+ pages to propound. You’d think that, after seven years, their command of the complexity of health care in this country would demand far more than a mere 100 pages! After all, we’re talking about the health care needs of millions of citizens. But this little fact seems to completely evade their thinking. Perhaps they can’t handle really big numbers.
    Another issue that Republicans – and conservatives in general – refuse to face is the incompatibility of a truly free-market, laissez-faire solution to this problem. After all, it’s just this system of free-lance social engineering (that ‘invisible hand’ of the marketplace) that has created the pitiable health-care practices and problems most of us are still living under and that the ACA sought to ameliorate for the least fortunate among us.
    Another issue not spoken of is – to my mind – the character of the health-care industry. What does it say about this industry that, even with the governmentally-created infusion of 20+ million new clients they still can’t make a profit! I know a number of small business people would pray for such government assistance. In short, the problem isn’t the government, it’s the industry.

  • Doug,
    You will always have MY vote as a World Series ring bearer for the Cubs. Maybe next year.

  • So many who call themselves Republicans would rather give a tax break to a wealthy person than help someone dying of cancer. How is it that so many Americans have become insensitive to the suffering of others? The only thing coming out of Congress this year is a law making it easier for the mentally ill to purchase guns. When did the U.S. become a third world country?

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