Friday, March 24, 2017

The TrumpRyanCare Debacle

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President Trump spoke about the failure of the Republican health bill on Friday at the White House. CreditAl Drago/The New York Times
Repealing the Affordable Care Act was meant to be the first demonstration of the power and effectiveness of a unified Republican government. It has turned out to be a display of incompetence and cruelty.
Republican leaders withdrew the American Health Care Act before a vote scheduled for Friday afternoon after it became clear that they did not have the votes to pass it. Many far-right conservatives opposed the bill because it would not have completely repealed the A.C.A., or Obamacare. And some more moderate Republicans said they would vote no because the bill would cause immense damage — 24 million people would lose health insurance over 10 years and millions of others would be hit with higher premiums and higher out-of-pocket costs. Surely, many of them were also thinking about a recent Quinnipiac University poll showing that 56 percent of American voters opposed the legislation and just 17 percent supported it.
When Barack Obama was president, Republicans in the House voted dozens of times to repeal the health care law in a symbolic exercise meant to appeal to their base. But never did they present a plan that could improve on the law for their constituents. Still, G.O.P. leaders imagined that with the House, Senate and White House in their hands, what had once been a hollow threat could become actual policy. That they failed in this legislative effort could well affect the rest of their agenda — tax cuts for the rich, changing the corporate tax structure and new infrastructure spending. The debacle shows President Trump and Paul Ryan, the speaker of the House, that they can’t count on automatic Republican majorities, especially when they’re offering a destructive, incoherent measure.
Which is pretty much what happened here. Despite their ceaseless attacks on the health care act since Mr. Obama signed it into law in March 2010, Mr. Trump, Mr. Ryan and their colleagues have never had a workable plan that could gain the support of a congressional majority. That is why they rushed their turkey of a bill to the floor without going through the laborious process of holding hearings and building coalitions. The last-minute wheeling and dealing did nothing to disguise the bill’s underlying and increasingly obvious purpose, which was to reduce taxes for the wealthy by cutting benefits for the needy.
Meanwhile, the great dealmaker at the White House was completely ineffectual. Mr. Trump spent a few days cajoling and threatening lawmakers, then threw up his hands and said he had done all he could and was now moving on to other matters. Groups representing doctors and hospitals, as well as public interest groups like AARP and the American Civil Liberties Union, fought hard, and even Republican governors like John Kasich of Ohio and Brian Sandoval of Nevada opposed the bill.
In fact, as Republicans moved closer to a vote, public support for Obamacare went up — 49 percent of those polled this month by the Kaiser Family Foundation had a favorable view of the law, up from 43 percent in December. Obamacare, though not without flaws, has done a world of good. The percentage of Americans who do not have health insurance has fallen to 9.1 percent, from 16.3 percent in 2010. A 2016 Kaiser study of people who gained insurance in California found that 77 percent of them said their health needs were being met very well or somewhat well. By comparison, only 49 percent of those people said their needs were being met three years earlier.
There is no doubt that improvements are needed. Deductibles and premiums are too high for many people, and too many young people are forgoing insurance altogether. More generous subsidies for people with modest incomes could bring the cost of health care down at a relatively small expense to the government.
The worry now among advocates for lower-income Americans and the sick is that the Trump administration might seek to undermine the health care law through administrative steps. For example, officials could seek to reduce subsidies that help people earning just above the federal poverty line pay for out-of-pocket costs. Republicans in the House sued the Obama administration in 2014 to block those subsidies. That case is still pending, and the Trump administration could decide to stop defending the subsidies. Such a move would only compound the mistakes it made by trying to rush a half-baked bill through the House.
Friday’s outcome is good for the country, but humiliating for the Republican leadership. For Mr. Trump, it is a rather brutal reminder that campaigning is the easy part.

The Scammers, the Scammed and America’s Fate

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Paul Ryan speaking on Capitol Hill last week. CreditEric Thayer for The New York Times
Many people are horrified, and rightly so, by what passes for leadership in today’s Washington. And it’s important to keep the horror of our political situation up front, to keep highlighting the lies, the cruelty, the bad judgment. We must never normalize the state we’re in.
At the same time, however, we should be asking ourselves how the people running our government came to wield such power. How, in particular, did a man whose fraudulence, lack of concern for those he claims to care about and lack of policy coherence should have been obvious to everyone nonetheless manage to win over so many gullible souls?
No, this isn’t a column about whatshisname, the guy on Twitter, who’s getting plenty of attention. It’s about Paul Ryan, the speaker of the House.
I’m writing this column without knowing the legislative fate of the American Health Care Act, Mr. Ryan’s proposed Obamacare replacement. Whatever happens in the House and the Senate, however, there’s no question that the A.H.C.A. is one of the worst bills ever presented to Congress.
Continue reading the main story
It would deprive tens of millions of health insurance — the decline in the number of insured Americans would be larger than what would result from simple repeal of Obamacare! — while sharply raising expenses for many of those who remain. It would be especially punitive for lower-income, older, rural voters.
In return, we would get a small reduction in the budget deficit. Oh, and a tax cut, perhaps as much as $1 trillion, for the wealthy.
This is terrible stuff. It’s made worse by the lies Mr. Ryan has been telling about his plan.
He claims that it would lower premiums; it would actually increase them. He claims that it would end the Obamacare death spiral; there isn’t a death spiral, and his plan would be more, not less, vulnerable to a vicious circle of rising premiums and falling enrollment. He claims that it would lead to “patient-centered care”; whatever that is supposed to mean, it would actually do nothing to increase choice.
Some people seem startled both by the awfulness of Mr. Ryan’s plan and by the raw dishonesty of his sales pitch. But why? Everything we’ve seen from Mr. Ryan amid the health care debacle — everything, that is, except the press coverage — has been completely consistent with his previous career. That is, he’s still the same guy I wrote about back in 2010, in a column titled “The Flimflam Man.”
I wrote that column in response to what turned out to be the first of a series of high-profile Ryan budget proposals. While differing in detail, all of these proposals share a family resemblance: Like his health plan, each involved savage cuts in benefits for the poor and working class, with the money released by these cuts used to offset large tax cuts for the rich. All were, however, sold on false pretenses as plans for deficit reduction.
Worse, the alleged deficit reduction came entirely from “magic asterisks”: claims about huge savings to be achieved by cutting unspecified government spending, huge revenue increases to be achieved by closing unspecified tax loopholes. It was a con job all the way.
So how did Mr. Ryan reach a position where his actions may reshape the lives of so many of his fellow citizens, in most cases very much for the worse? The answer lies in the impenetrable gullibility of his base. No, not his constituents: the news media, who made him what he is.
You see, until very recently both news coverage and political punditry were dominated by the convention of “balance.” This meant, in particular, that when it came to policy debates one was always supposed to present both sides as having equally well-founded arguments. And this in turn meant that it was necessary to point to serious, honest, knowledgeable proponents of conservative positions.
Enter Mr. Ryan, who isn’t actually a serious, honest policy expert, but plays one on TV. He rolls up his sleeves! He uses PowerPoint! He must be the real deal! So that became the media’s narrative. And media adulation, more than anything else, propelled him to his current position.
Now, however, the flimflam has hit a wall. Mr. Ryan used to be able to game the Congressional Budget Office, getting it to produce reports that looked to the unwary like proper scores of his plans, but weren’t. This time, however, he couldn’t pull it off: The C.B.O. told the devastating truth about his plan, and his evasions and lies were too obvious to ignore.
There’s an important lesson here, and it’s not just about health care or Mr. Ryan; it’s about the destructive effects of false symmetry in reporting at a time of vast asymmetry in reality.
This false symmetry — downplaying the awfulness of some candidates, vastly exaggerating the flaws of their opponents — isn’t the only reason America is in the mess it’s in. But it’s an important part of the story. And now we’re all about to pay the price.
Continue reading the main story

Thursday, March 23, 2017

Trump Tells G.O.P. It’s Now or Never, Demanding House Vote on Health Bill

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Representatives Jim Jordan of Ohio and Raúl R. Labrador of Idaho, members of the House Freedom Caucus, discussed the American Health Care Act on Thursday.CreditStephen Crowley/The New York Times
WASHINGTON — President Trump issued an ultimatum on Thursday to recalcitrant Republicans to fall in line behind a broad health insurance overhaul or see their opportunity to repeal the Affordable Care Act vanish, demanding a Friday vote on a bill that appeared to lack a majority to pass.
The demand, issued by his budget director, Mick Mulvaney, in an evening meeting with House Republicans, came after a marathon day of negotiating at the White House and in the Capitol in which Mr. Trump — who has boasted of his deal-making prowess — fell short of selling members of his own party on the health plan.
House Speaker Paul D. Ryan emerged from the session and announced curtly that Mr. Trump would get his wish for a vote on Friday. Mr. Ryan refused to answer reporters’ questions about whether he expected the measure to pass.
Although the House Republicans’ closed-door meeting became a cheerleading session for the bill, their leaders braced for a showdown on the floor, knowing they were likely to be at least a handful of votes short of a majority for the health insurance bill and would need to muscle their colleagues to the last to prevail.

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The Parts of the Affordable Care Act That the Republican Bill Will Keep or Discard

A comparison of the bill with key components of the Affordable Care Act.
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Some conservatives were still concerned that the bill was too costly and did not do enough to roll back federal health insurance mandates. Moderates and others, meanwhile, were grappling with worries of their states’ governors and fretted that the loss of benefits would be too much for their constituents to bear.
Continue reading the main story
Mr. Ryan had earlier postponed the initial House vote that was scheduled for Thursday to coincide with the seventh anniversary of the Affordable Care Act’s signing. Mr. Trump confronted the possibility of a humiliating loss on the first significant legislative push of his presidency.
At a White House meeting with members of the hard-line Freedom Caucus earlier on Thursday, Mr. Trump had agreed to the conservatives’ demands to strip federal health insurance requirements for basic benefits such as maternity care, emergency services, mental health and wellness visits from the bill. But that was not enough to placate the faction, part of the reason that Thursday’s vote was placed on hold.
As House leaders struggled to negotiate with holdouts in the hopes of rescheduling the vote, Mr. Trump sent senior officials to the Capitol with a blunt message: He would agree to no additional changes, and Republicans must either support the bill or resign themselves to leaving President Barack Obama’s signature domestic achievement in place.

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Even if Health Bill Passes the House, It Still Has a Way to Go

Lawmakers will have to clear several hurdles before it’s ready for President Trump’s signature.
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“We have a great bill, and I think we have a good chance, but it’s only politics,” Mr. Trump said earlier Thursday, as it was becoming clear that his negotiating efforts had failed to persuade enough members of his party to back the plan — which was years in the making — to repeal and replace the health law.
Privately, White House officials conceded that competing Republican factions were each demanding changes that could doom the effort, placing the measure in peril and Mr. Trump’s chances of succeeding at a high-stakes legislative deal in jeopardy. With some of its demands in place, the Freedom Caucus ratcheted up its requests, insisting on a repeal of all regulatory mandates in the Affordable Care Act, including the prohibition on excluding coverage for pre-existing medical conditions and lifetime coverage caps.
Mr. Trump, who has touted his negotiating skills and invited the label “the closer” as the vote approached, was receiving a painful reality check about the difficulty of governing, even with his own party in power on Capitol Hill.
“Guys, we’ve got one shot here,” he told members of the Freedom Caucus at a meeting in the Cabinet Room, according to a person present in the room who spoke on the condition of anonymity because the meeting was private. “This is it — we’re voting now.”
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The White House press secretary, Sean Spicer, spoke to reporters on Wednesday.CreditDoug Mills/The New York Times
“The choice is yes or no,” Representative Joe Barton, Republican of Texas and a member of the Freedom Caucus, said on Thursday night. “I’m not going to vote no to keep Obamacare. That’d be a stupid damn vote.”
Others were unconvinced.
Having secured Mr. Trump’s acquiescence to eliminate the requirement that insurers offer “essential health benefits,” members of the Freedom Caucus pressed their advantage. While they did not specify precisely which regulations they wanted to eliminate, the section they wanted to gut requires coverage for pre-existing health conditions, allows individuals to remain on their parents’ health care plans up to age 26, bars insurers from setting different rates for men and women, prohibits annual or lifetime limits on benefits, and requires insurers to spend at least 80 percent of premium revenue on medical care.
“We’re committed to stay here until we get it done,” said Representative Mark Meadows, Republican of North Carolina and the chairman of the Freedom Caucus. “So whether the vote is tonight, tomorrow or five days from here, the president will get a victory.”
He said 30 to 40 Republicans planned to vote “no”; House leaders can afford to lose only 22 in order to pass the bill.

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C.B.O. Update: Health Bill Amendments Will Cost More But Not Insure More

Details from the Congressional Budget Office’s analysis of the revised Republican health plan.
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But for every concession Mr. Trump made to appease critics on the right, he lost potential rank-and-file supporters in the middle, including members of the centrist Tuesday Group who had balked at the bill’s Medicaid cuts and slashed insurance benefits. Moderate Republicans in that group went to the White House on Thursday but emerged unmoved in their opposition.
“There’s a little bit of a balancing act,” conceded Sean Spicer, the White House press secretary.
Representative Leonard Lance, Republican of New Jersey, said he still opposed the bill because he did not believe it would give people “complete and affordable access” to health insurance.
At the same time, a new estimate of the bill’s cost and its impact on health coverage further soured the picture for wavering lawmakers. The nonpartisan Congressional Budget Office on Thursday issued a report on the revised version of the health care bill showing that it would cost more than the original version but would not cover more people. The report said the bill, like the original version, would result in 24 million fewer Americans having health insurance in 2026 than under current law.

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How the Rich Gain and the Poor Lose Under the Republican Health Care Plan

Breakdown of how much people gain or lose under the plan.
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But recent changes to the bill, made through a series of amendments introduced on Monday, would cut its deficit savings in half. Instead of reducing the deficit by $337 billion, the new version of the bill would save only $150 billion over the decade.
The budget office did not consider the effects of various additional changes that remain under negotiation, including eliminating benefit requirements and other health insurance regulations.
Quinnipiac University national poll found that voters disapproved of the Republican plan by lopsided margins, with 56 percent opposed, 17 percent supportive and 26 percent undecided. The measure did not even draw support among a majority of Republicans; 41 percent approved, while 24 percent were opposed.
President Trump appealed to supporters to weigh in, assuring them in a video on Twitter, “Go with our plan. It’s going to be terrific.”
The chaotic process that unfolded on Thursday exposed Republicans to criticism that they were moving recklessly in a desperate bid to get their plan passed. Representative Raúl Labrador, Republican of Idaho and a Freedom Caucus member, said the party’s leaders had tried to ram through the measure over their members’ objections. He panned what he described as a “brute force” strategy that resembled the approach of former Speaker John A. Boehner, Republican of Ohio.
“It’s better to get it right than to get it fast,” Mr. Labrador said.
It was not clear that the changes that Mr. Trump has agreed to and those being demanded could survive. Under the strict budget rules being used to advance the bill, changes to the Affordable Care Act must affect federal spending or revenues. Regulatory measures that affect private health policies, not government programs like Medicaid, are highly likely to be challenged by Senate Democrats. If the Senate parliamentarian rules in the Democrats’ favor, those changes in the House would be stripped from the bill.
The emerging power of the Freedom Caucus, a group that has been historically marginalized in policy making but a thorn in the side of leadership, is one of the surprises of the rushed health care debate. The group has been empowered by the addition of Mr. Mulvaney to the senior White House staff, and Mr. Trump’s disengagement from policy details, coupled with his intense desire to score a win after a rocky start to his presidency.
Mr. Obama stepped into the fray on Thursday with a lengthy defense of his law on the seventh anniversary of its signing, and a call for bipartisan improvements.
 
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Millions Stand to Lose Addiction Treatment

Treatment for addiction grew with the Medicaid expansion under Obama’s health care act, but millions may lose coverage if the House approves a measure to repeal the Affordable Care Act.
 By NILO TABRIZY and AINARA TIEFENTHÄLER on Publish DateMarch 23, 2017. Photo by Nilo Tabrizy. Watch in Times Video »
“I’ve always said we should build on this law, just as Americans of both parties worked to improve Social SecurityMedicare, and Medicaid over the years,” he wrote in a mass email to followers. “So if Republicans are serious about lowering costs while expanding coverage to those who need it, and if they’re prepared to work with Democrats and objective evaluators in finding solutions that accomplish those goals — that’s something we all should welcome.”
The Affordable Care Act requires insurers to provide “essential health benefits” in 10 broad categories, including maternity care, mental health care, addiction treatment, preventive services, emergency services and rehabilitative services.
Mr. Spicer defended the removal of the “essential health benefits” regulations, saying that it would accomplish Mr. Trump’s stated goal of reducing health care costs. “Part of the reason that premiums have spiked out of control is because under Obamacare there were these mandated services that had to be included,” Mr. Spicer said.
Family planning groups and advocates for women’s rights criticized Republican plans to roll back these requirements.
“Paul Ryan and his House members are willing to sell out the moms of America to pass this bill,” said Dawn Laguens, an executive vice president of the Planned Parenthood Federation of America.
Conservatives say the mandates, as interpreted in rules issued by the Obama administration, add to the costs of health insurance and make it difficult for insurers to offer lower-cost options to meet consumers’ needs.
Democrats say that the purpose of insurance is to share risk, and that without federal requirements, insurers would once again offer bare-bones policies. Before the Affordable Care Act took effect, maternity coverage was frequently offered as an optional benefit, or rider, for a hefty additional premium.
Correction: March 23, 2017 
Because of an editing error, an earlier version of a picture caption with this article misstated the day that Sean Spicer, the White House press secretary, was photographed speaking to reporters. The photograph was taken Wednesday, not Thursday.

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