Thursday, March 09, 2017

"Moderate" Republican opposition to AHCA is looking very squishy

Hours before House Republicans published a full draft of their ACA repeal-and-replace bill, the so-called American Health Care Act, four Republican senators in states that have expanded Medicaid -- Portman, Capito, Gardner and Murkowski -- sent a letter to Mitch McConnell from warning that the repeal bill should provide "stability" for beneficiaries of the expansion.

Given the letter's timing, and its expressed concern for beneficiaries of the Medicaid expansion, some accounts of the repeal bill's release (e.g., Chait's) interpreted it as opposition to the bill. But it was not that. In fact it may have been the opposite. Those who are anticipating rejection of the House bill by Senators who have expressed qualms about un-insuring expansion beneficiaries should take warning.

The letter from Portman et al warned about provisions in a draft of the AHCA that leaked on February 10, protesting that that draft
does not meet the test of stability for individuals currently enrolled in the program and we will not support a plan that does not include stability for Medicaid expansion populations or flexibility for states.
What the letter did not do was call for maintaining funding for the expansion over an extended period. Rather it demanded
that any health care replacement provide states with a stable transition period and the opportunity to gradually phase-in their populations to any new Medicaid financing structure.
Having opened space for "transition", the letter neatly elides the distinction between changing funding structure and cutting funding, or disrupting access to healthcare and ending it:
We believe Medicaid needs to be reformed, but reform should not come at the cost of disruption in access to health care for our country’s most vulnerable and sickest individuals. Any changes made to how Medicaid is financed through the state and federal governments should be coupled with significant new flexibility so they can efficiently and effectively manage their Medicaid programs to best meet their own needs. We also believe a gradual transition is needed to ensure states have the time to successfully implement these new changes. 
Not surprisingly, then, none of these senators have suggested that they will vote against the AHCA, though they've hinted that the final version that comes to a Senate vote may be somewhat different from the current draft. Here's an account of Cory Gardner at a Town Hall on March 8:
Sen. Cory Gardner repeated his position against any replacement that doesn’t protect Coloradans who gained Medicaid under Obamacare. He first took that stance in letter responding to a February draft of the bill. During his telephone town hall, Gardner didn’t say whether the current House bill met his standard.

"We've got to make sure we have something better than what we have today," Gardner said. "And I hope that's the goal of every Republican and Democrat in the United States Congress."

He found one thing he like about the ACHA: it strips Planned Parenthood of federal funding in favor of federally qualified health care clinics. That’s long been a priority for the pro-life Republican.

Otherwise, the senator took a wait-and-see approach on the House bill, saying he’d “continue to engage in these kinds of discussions to make sure we get this right for the American people.”
And here's Rob Portman after a meeting today with Pence and Price:
“As I have said before, I support making structural improvements to the Medicaid program, but we must provide stability and certainty for individuals and families in Medicaid expansion programs and real flexibility for states,” Portman said in a statement. “I will continue to work with the administration and my colleagues to address these concerns.”
And here's Portman again, in response to Trump indicating he might be willing to see the bill amended to phase out the Medicaid expansion in 2018 or 2019 instead of 2020:
"Bad idea," said Sen. Rob Portman of Ohio, one of four GOP senators to warn the House to keep millions of low-income Americans in mind as the chamber considers the bill. "I hope it won't be [adopted] because I think it's moving backwards ... it makes it harder for some of us."
Harder to what? Vote for a bill that in its current form would end the Medicaid expansion and impose per capita caps on the federal contribution to Medicaid, ensuring that the federal shre won't keep pace with actual cost increases.

If right wing critics of the AHCA fall into line, Democrats cannot count on relative moderates holding out in fear of un-insuring tens of millions.  That's why I think Democrats should work to shore those relative moderates up by signaling that a more, um, moderate compromise is possible.

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