Diagnosis for Democracy
Insights into the State of Our Union
A Blog by Rob Tenery, MD


The Republicans Just Couldn't Get Their Act Together

By Rob Tenery, MD on March 27, 2017

Since 2006, the Republican controlled House of Representatives have voted to overturn Obamacare over 60 times. Now with their own Republican president pleading for them to send him replacement legislation, they failed to deliver. Almost to the person these Republican members of the House campaigned and won on the promise they would throw out the current law and replace it with a new and improved version. So why did they fail to even get a bare majority to come together on legislation that could be sent on to the Senate.

The first reason, unlike the Democrats, who, except for maybe the Black Caucus, stay in lockstep with their leadership. The Republicans are divided into factions; the study committee, the conservative Freedom Caucus, the more moderate Tuesday group, the Saturday group who are aligned against Trump, the left-leaning Rhinos and the right leaning Tea Party members. Despite what they promised, when each knew they would be held accountable for their vote, both to their constituency and their caucus, as a group, they were not able to put together a consensus. With the 2018 reelection looming, these very same individuals must know that if they don’t deliver on revising or replacing Obamacare, there is a good chance many of them won’t be around. This also includes the Democrats, who are up for reelection too in the House and Senate.

It then should be of no surprise that the replacement to Obamacare will be brought up again before the next election cycle. This time, my guess, the Republican leadership will have the votes lined up to pass a bill on to the Senate, rather than face the humiliation of this last week.

As Donald Trump found out, repealing or replacing Obamacare is not as simple as he portrayed in his many campaign speeches. Many hurdles exist, but these below are near the top of the list. First is to protect those who have already obtained coverage under this program. Second is to continue to offer affordable coverage or supplements to those with significant pre-existing conditions. Three is what to do with the existing and the newly expanded state Medicaid programs. Forth is what to do about the existing taxes that came with the legislation. Fifth would be how to bring in additional funds to pay for these expanded health care benefits such as by health care savings accounts and vouchers. The last would be to encourage competition in the insurance industry by expanding competition across state lines.

What happened to the Republican plan? There will be a lot of finger-pointing all around about who did or didn’t do what to keep it from passing. So Paul Ryan pulled the bill rather than have it voted down. There are several important reasons contributing to why it was pulled. The most obvious is that many of the most conservative factions, within the party, were not allowed into the original markup of the plan. It is not surprising then that enough Republicans bolted to keep it from passing out of the House.  The current version only needed a simple majority, using reconciliation (51), votes to pass. This option evidently expires in August. If the vote had failed or if any new health care legislation is brought up again after August, reportedly it will have to pass by 60 votes.

According to supporters of the Ryan/Trump plan, it was drawn so that it would have left part as a carry over from Obamacare to maintain the ability of the Secretary of Health and Human Services to act independently in ‘cleaning up’ the unreasonably costly ‘essential health benefits’, such as male enrollees paying for maternity benefits and general mental health coverage.

Most in the media, on both sides, have claimed this was a failure of Donald Trump’s leadership. However, his failure was in trusting his Party to come together to bring him a viable alternative that would repeal and replace Obamacare. It appears that he and his Vice President did all they could to muster support. But, it was too late. He will have learned a great lesson that will help him the next time around, with tax reform and building the wall.

The answer is to start by Trump making certain that a consensus is convened of Republican House of Representative members, Democrat members and medical experts from organizations such as the American Medical Association, the Brookings Institution and the Heritage Foundation to write the next proposed health care legislation. Then getting a simple majority won’t be a problem.

Something that affects the lives of all of the American People and is quickly approaching 20% of U.S. spending deserves better the next time around.





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