It's now nearly a month after President Trump took office, and the planned "repeal and replace" of Obamacare/the Affordable Care Act has not yet taken shape or place. We're no closer to knowing what the Republican plan is, although they have had six years to settle on an opposing plan. There are currently multiple Republican health care plans, and no consensus unifying theme.
Instead of diving into the weeds of which plans are likely, what changes are happening, etc., I wanted to examine exactly why it is that the Republicans are having such a hard time uniting. It was easy to say Obamacare was terrible. It was harder to build something of their own.
There are Republican plans out there. Paul Ryan has "A Better Way." Secretary of Health and Human Services Tom Price (while he was a U.S. Representative) put out his own plan, the Empowering Patients First Act. Sen. Orrin Hatch and friends released the Patient CARE Act. Sen. Ted Cruz has the Health Care Choice Act. President Trump's health care plan is... incomplete and a few paragraphs long. It kind of lists a few Republican ideas, but little concrete. There are also a couple conservative think tank plans out there that are far more thought out.
But the question isn't "Do the Republicans have a plan?" but "Why can't they agree on what to do?"
Part of that comes from philosophical differences, part of it comes from the sticky position that the ACA left them in, and part of it comes from problems of their own making. Let's tackle some of those issues.
First, there's the question of how much to repeal. Hard-right conservatives wish to throw out the whole kit and caboodle. They're growing increasingly angry that they haven't been able to fulfill their promise to repeal Obamacare yet. But the ACA is a vast and tricky thing. If you throw out all of it, you're taking away 10-20 million people's health insurance, you're taking away protections for consumers (read: no denial for pre-existing conditions, children can stay on parents' plans until age 26, etc.) and more. Those of a more moderate bent know that some of those provisions are highly favored by the general public. They're reluctant to throw all of the ACA out, because then the GOP is the bad guy that "took away my health care."
Second, there's the question of whose costs need to be lowered. Fiscal conservatives take issue with how expensive the ACA is on the government. Others, like occasionally President Trump, have argued that the ACA is too expensive for individual people, through premiums and deductibles. The problem is you can't fix one problem without hurting the other. Let's say the fiscal conservatives win out — premiums and deductibles will rise for some group or coverage will be cut as a result. If Trump's side wins, the government spending on health care rises more. There is no way to bridge that gap.
Third, there's the question of who should have coverage. Some argue that the goal of health care should be universal health care coverage, "even those who can't pay for it." Others believe that GOP should make it clear: "We don't believe it's the federal government's job to make sure everyone has health insurance."
Fourth, there's the question of how to pay for a new health care plan. This one's a biggie. The ACA raised its nearly $100 billion a year through taxes on the rich and some new revenue streams. The GOP hates those taxes. Get rid of them! But then the question is how to make up for that, and... there's the catch. According to leaked audio from a Republican gathering last month, there are talks to start taxing some or all of the employer-paid health plans most of us get. Those are currently exempt from taxes. That would be bad politically, and other Republicans pushed back in that very meeting.
Fifth, there's the question of Medicaid expansion. About 20 of the 52 GOP senators have said they wouldn't vote for any ACA fix that didn't keep the largely popular Medicaid expansion that their state chose to do. But other Republicans from states that chose not to expand Medicaid want to know that their principled stands were not in vain. They want to know that they did the right thing, and to see those states that caved admit they were wrong to expand Medicaid.
Sixth, there's the question of who will bear the brunt of the changes. Several of the GOP plans call for a change in the ratio of costs. In essence, the ACA limited the cost health care plans for older people to no more than 3:1 of the health care plans for younger people. The Ryan and Hatch plans both call to make this 5:1 instead. One of the conservative think tanks called for it to be 6:1. In short, one writer found the GOP plans would shift costs to older, sicker patients rather than the ACA's younger, healthier patients.
Seventh, and related, there's the question of how to determine subsidies. Right now, subsidies are based on income -- the less money you have, the more government help you get in return. Some of these plans call for either getting rid of all subsidies or changing subsidies to an age-based system.
There are more issues at hand, but these give you some of the basic problems the GOP is fighting right now. In that leaked audio, one Republican said that they've got to get the Obamacare fix right, because if they don't, it'll be called "Trumpcare" and they'll all have that as an albatross around their necks. Personally, I'd be more worried about doing what's right for the country and for your constituents than what would be most embarrassing.
Where the Power Lies
For a minute there, I thought that the Flynn/Russia thing was going to have legs. I thought that maybe this — this? — would be the thing that brought President Trump down. A few Republicans in the House and Senate, including our own Sen. Roy Blunt, started to call for an independent investigation of Russian ties to President Trump and his campaign. And then... nothing.
Meanwhile, I heard an interesting perspective from liberal comedian Samantha Bee, talking about how the real power in Congress is Paul Ryan. Notably, that he's the man to watch for reactions to the President. Right now, Ryan is probably content to ride Trump as long as he can — the same voters that elected Trump also elected the representatives that gave Ryan power. But Ryan, as Speaker of the House, is the man tasked with writing articles of impeachment, should that ever have to come to pass.
So that's the tentative alliance here: fiscal conservative, traditional Republican Paul Ryan with brash, hard-to-pin-down, nontraditional Republican Donald Trump. It's in the best interests of both to work nicely with the other. I'll be watching to see which side burns the bridge first. The one that burns the bridge first will be the one that thinks they have the moral superiority.
Good News from Gates Report (Vlogbrothers)
The Vlogbrothers pointed this out, but Bill and Melinda Gates issue a letter each year, and this time it was to Warren Buffett. It talks about the good their organization has done. There's a lot of good that's been done, so let's hit the high notes, because this reminds you that life is making major strides:
• The number of childhood deaths per year has dropped in half since 1990. The trend line has been revised downward twice.
• The number of children worldwide receiving vaccines is at its highest point in history -- 86 percent. The gap between rich countries (96 percent) and poor countries (80 percent) is the smallest it's ever been.
• It took decades to get 200 million women on modern contraceptives. It took another 13 years to get to 300 million women on contraceptives.
• Extreme poverty has been cut in half since 1990.
• There were only 37 new cases of polio last year. Not in the U.S. Not in North America. IN THE WORLD.
In a world in which there isn't a lot of hope, These things remind me of the good being done in our world.
News Judgments
Although there are good news stories, I bring you an interesting perspective from my friend and former OU colleague Adam Croom. He still works at OU in an interesting role, but he ended up meeting with the first African-American to own a home in Norman. After Adam told him thank you... for everything, Dr. George Henderson said, "I would have never believed that in 2017, we would be starting the battle all over again." Powerful story. Read it here. • • • A friend of mine (Hi, Allie!) asked my thoughts on a newspaper in Colorado being called "fake news" by a lawmaker and threatening to sue the lawmaker for libel. After talking about it with Alyson, I have a few observations. 1) It's a relatively untapped legal field -- a newspaper not as the defendant of a libel suit, but a plaintiff. I think they have an argument that they were defamed, but whether it was legal or not is a different question. 2) That's because a newspaper will probably fall under the higher burden of proof for libel of a "public figure." It means the paper would have to prove "actual malice" -- that the lawmaker had deliberately bad intentions when he made his remarks. It's a higher burden of proof, which means the case is tougher. 3) I didn't say they didn't have a case. If they sue and win, maybe this emboldens other organizations in more high-profile situations to make a similar stance? • • • I've been sick or the kids have been sick a lot this week, so my running has been rather disjointed. I have run up to 2.5 miles, so that's good, with a month until I run a 4-miler. But it's getting warmer and we're all hopefully getting healthier, so I hope that changes soon. • • • Some of the better Evie-Roland stories have already been on Facebook, but there's one that hadn't been. The kids were pretty sick last weekend, and at one point, we heard an unpleasant noise come from the kitchen. "What was that noise?" I asked to the kids. "Evie," she admitted. "Was it a butt noise?" "Yeah." So now the go-to phrase for farts or poops is "butt noises."
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