Monday, March 13, 2017

Squish!

The meme that Republican senators in states that have embraced the ACA Medicaid expansion will block the House repeal bill from passing substantially as is and save the expansion continues. Here's Politico's Burgess Everett with news of a closed-door meeting in Nevada:
Sen. Dean Heller panned House Speaker Paul Ryan's bill to repeal and replace Obamacare during a closed meeting with constituents on Saturday, according to audio obtained by POLITICO.

The remarks by Heller, the most vulnerable GOP senator on the ballot next year, are another sign of the difficult prospects the House bill faces in the other chamber. Already, more than a half-dozen senators have criticized the bill, and Republicans can afford to lose only two votes.
Hail defender! As Nevada's Republican governor, Brian Sandoval, boasted in a letter to the House leadership in January, Nevada has slashed its uninsured rate almost in half since ACA enactment, from 23% to 12% -- mainly through the Medicaid expansion, which has increased Medicaid enrollment by 288,000 since September 2013 in a state with 2.5 million residents. Plenty to defend!

So what is Heller's promise to Nevadans? Back to Politico:
The House bill would keep the expansion through 2019 before winding it down, although some conservatives want to begin gutting it earlier.

“They’re talking about 2020, now they’re talking about making the changes in 2018,” Heller said. “That’s not enough time for Nevada to adjust. We need time to adjust. I want to move that thing up four or five years," he added, referring to a longer delay. 
Got that? Two more years till cutoff, maybe three. Let's un-insure Nevadans more slowly! I wonder if anyone asked Heller how he feels about the strangling of overall Medicaid spending long-term via the per-capita caps stipulated in the House bill (the so-called American Health Care Act, or AHCA).

Now, Heller did say that he was "urging Vice President Mike Pence and Senate Majority Leader Mitch McConnell to allow the Senate to make significant changes to the bill."  Good, but what changes (besides delaying but not removing defunding of Medicaid expansion)? Tax cuts not thorough enough for him?
Heller also said he opposed the bill’s preservation of the so-called Cadillac tax on high-cost insurance plans. Heller and Sen. Martin Heinrich (D-N.M.) have sought to kill the tax for years.

“My argument with the Republicans is if we’re going to make the changes, don’t repeal the Affordable Care Act so you can keep all the taxes. I think that’s unfair and I don’t think that’s a responsible way to move forward,” Heller said. The House bill does eliminate some taxes on wealthy people.
That appears to mean: If you're going to repeal the ACA (good), don't preserve the taxes (i.e., the Cadillac tax) rather than 'don't repeal the ACA just so those whom it taxes can keep the proceeds." Hence Everett's fact-check with regard to the AHCA's repeal of "some taxes on wealthy people" -- along with every other tax but the Cadillac tax, he might have added. In any case, a Cadillac tax postponed to 2025, as AHCA does, will pretty plainly never be implemented.*

The implication that Heller "defended" the Medicaid expansion at this meeting replicates coverage of the letter to McConnell sent by R. Senators Portman (OH), Capito (WV), Gardner (CO) and Murkowski (AK), hours before the repeal bill was released. This letter criticized the leaded February 10 draft of the bill and was widely reported as a defense of the Medicaid expansion and implicit rejection of the bill that came out later the same day.

But as I noted last week, it wasn't that. The letter proclaimed  "we will not support a plan that does not include stability for Medicaid expansion populations or flexibility for states." That kicker (my emphasis) is code for imposing per-capita caps on Medicaid, as the repeal bill does, which will probably inflict more long-term damage on Medicaid than repeal of the ACA expansion.

And as for the latter...like Heller, the Portman crew really called only for a stay of execution, demanding
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.
Phasing expansion enrollees into a new Medicaid financing structure means phasing them out of Medicaid. Have any of the Portman 4 said they won't vote for the AHCA? Show me.

Right-wing rejection of the AHCA will likely wither in the heat of Trump's all-in support and threats of retaliation.  As for the purported moderates...their opposition is likely to go the way of the prospective support of Senators Grassley Enzi of Snowe for the ACA-in-progress in the long hot summer of 2009.

While applying maximum force to expose the AHCA's gaping flaws, Democrats also need a means to shore those moderates up. Cassidy-Collins, anyone?

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* In first read, I missed this comment re the ACA's taxes because of a scrolling jump -- discussion of Heller's tax comments added as update. 

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