GOP vexed by fac­tions on re­plac­ing health law

Kuwait Times - - ANALYSIS -

Repub­li­cans are united on re­peal­ing Pres­i­dent Barack Obama’s health care law, but ide­o­log­i­cally and prac­ti­cally speak­ing, they’re in dif­fer­ent camps over re­plac­ing it. Get­ting the fac­tions to­gether won’t be easy. Some Repub­li­cans would re­vise and re­brand “Oba­macare,” junk­ing un­pop­u­lar pro­vi­sions like its re­quire­ment that most Amer­i­cans carry health in­sur­ance, while pre­serv­ing well-liked parts. Oth­ers would rip up the Af­ford­able Care Act, or ACA, and not re­place it.

Pres­i­dent-elect Don­ald Trump and Repub­li­can con­gres­sional lead­ers will have to unite the groups on com­pli­cated changes af­fect­ing the fi­nan­cial and phys­i­cal well-being of mil­lions of peo­ple. For some con­stituents in frag­ile health, it’s lit­er­ally a life-and-death de­bate. Repub­li­cans have “a re­ally nar­row path,” says Grace-Marie Turner of the Galen In­sti­tute, a free-mar­ket health care re­search or­ga­ni­za­tion. “They’ve got to deal with the pol­i­tics of this, they’ve got to make sure they come up with good pol­icy, and they also have process chal­lenges.”

Suc­cess is not guar­an­teed, and Repub­li­cans may come to re­gret that their party de­fined it­self as to­tally op­posed to “Oba­macare.” Yet House Ways and Means Chair­man Kevin Brady seems un­fazed by the chal­lenge. “It’s like tax re­form,” says Brady, ex­plain­ing that many pieces will be pulled to­gether. “Un­like Oba­macare, which ripped up the in­di­vid­ual mar­ket, this will be done de­lib­er­ately, in an ap­pro­pri­ate timetable.” Repub­li­cans say they will move quickly to re­peal the ACA, while sus­pend­ing the ef­fec­tive date to al­low them to craft a re­place­ment. Here’s a look at the GOP camps and who’s in them:

Re­vise & re­brand

Many Repub­li­cans may qui­etly be in this con­tin­gent, but fear being ac­cused of pro­mot­ing “Oba­macare-lite”. They’d strip out some of the ACA’s taxes and re­quire­ments. The un­pop­u­lar “in­di­vid­ual man­date” to carry health in­sur­ance or risk fines could be re­placed with other per­sua­sion short of a gov­ern­ment dic­tate. Rules on in­sur­ers would be loos­ened.

But pop­u­lar pro­vi­sions such as pro­tect­ing those with pre-ex­ist­ing health con­di­tions would be re­tained in some form, as well as fi­nan­cial as­sis­tance for low- and mod­er­ate-in­come peo­ple. The re­quire­ment that health plans cover adult chil­dren un­til age 26 would be fairly easy to pre­serve, since em­ploy­ers have ac­com­mo­dated it.

A re­branded ver­sion of Obama’s law may well cover fewer peo­ple. But its GOP ad­vo­cates believe most Amer­i­cans will find their goal of “uni­ver­sal ac­cess” politically ac­cept­able when mea­sured against the Demo­cratic ideal of “uni­ver­sal cov­er­age” un­der­writ­ten by gov­ern­ment. Many GOP al­lies in the busi­ness com­mu­nity fa­vor re­vis­ing the ACA. That in­cludes ma­jor play­ers among hos­pi­tals, in­sur­ers and phar­ma­ceu­ti­cals. Trump may have given this group some cover by say­ing that he wants to keep parts of the law, but his bot­tom line re­mains un­known.

For bud­get hawks, un­wind­ing the Obama health law is a be­gin­ning. Next they could move on to much big­ger ob­jec­tives like re­struc­tur­ing Med­i­caid and Medi­care, and plac­ing a cost-con­scious limit on tax breaks for em­ployer cov­er­age. Bud­get hawks see health care as the main driver of gov­ern­ment deficits, and they are loath to ad­dress that im­bal­ance by rais­ing taxes. In­stead they want to re­write the social com­pact so in­di­vid­u­als ac­cept more re­spon­si­bil­ity and risk for their health care.

House Speaker Paul Ryan is the most prom­i­nent mem­ber of this camp, and his “Better Way” agenda is its roadmap. Ge­or­gia Rep Tom Price, Trump’s nom­i­nee for Health and Hu­man Ser­vices, is a bud­get hawk. Vice Pres­i­dent-elect Mike Pence has been in the same or­bit through­out his ca­reer. The prob­lem for bud­get hawks is that the 2016 po­lit­i­cal cam­paign did not give them a man­date. Is­sues like Medi­care and Med­i­caid were scarcely dis­cussed. Trump said he wouldn’t cut Medi­care, and sent con­flict­ing sig­nals on Med­i­caid. Many Democrats can’t wait for Repub­li­cans to fol­low the call of the bud­get hawks. Bet­ting that will back­fire, House Demo­cratic Leader Nancy Pelosi is ral­ly­ing her law­mak­ers against “at­tacks on the ACA and Medi­care.”

The rip-it-up so­ci­ety

The most con­ser­va­tive law­mak­ers want to “pull Oba­macare up by the roots as if it never ex­isted,” says Repub­li­can po­lit­i­cal con­sul­tant Frank Luntz. That sen­ti­ment is em­bod­ied by the 40 or so mem­bers of the House Free­dom Cau­cus, and it’s prob­a­bly broadly shared among con­ser­va­tives. Some do not believe the fed­eral gov­ern­ment should be in­volved in health care, and they couldn’t care less about re­plac­ing the ACA. “They would say that Obama’s plan has failed,” said Luntz. GOP lead­ers may need these law­mak­ers to ad­vance on re­place­ment leg­is­la­tion; coax­ing them to a mid­dle ground might not be pos­si­ble. Trump calls the ACA “a dis­as­ter,” and that’s pleas­ing to those far­thest on the right. It’s un­clear if he’d walk their walk.

At the core of this small group are leg­isla­tive vet­er­ans who un­der­stand the ex­cru­ci­at­ing dif­fi­cul­ties of get­ting ma­jor bills to a pres­i­dent’s desk. GOP Sens. La­mar Alexan­der of Ten­nessee and Su­san Collins of Maine are prag­ma­tists. They may find sup­port from Repub­li­can gov­er­nors who ex­panded Med­i­caid un­der the health law. GOP con­gres­sional lead­ers could grav­i­tate to this camp. The big­gest chal­lenge for prag­ma­tists will be to win over some Democrats for re­place­ment leg­is­la­tion. While re­peal­ing most of “Oba­macare” is pos­si­ble with a sim­ple ma­jor­ity in the Se­nate, 60 votes would prob­a­bly be needed for a re­place­ment. There will only be 52 GOP sen­a­tors next year.

“Repub­li­cans need a fancy Rose Gar­den re­peal cer­e­mony...and I ex­pect them to have one,” said Dan Men­del­son, CEO of the con­sult­ing firm Avalere Health. “On the other hand, there’s 20 mil­lion peo­ple with health in­sur­ance un­der the ACA, and they don’t want to dump them. There’s no clear path for how to square that con­flict.” —AP

In this Oct 24, 2016 file photo, the Health­ 2017 web­site home­page is seen in Wash­ing­ton. —AP

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