A BFD that passed amongst the chaos

In most strands of the multi-verse, the below would have sent the health wonk community ablaze. Instead in this strand, we spent all day yesterday talking about a proposed rule from CMS and generally shaking our head as our government continues to say “Hold my beer and watch this….”

But this is normally a BFD:

What does this mean?

Repeal and Replace or Repeal and Delay and Pray is dead. There is no coherent coalition of 218 and 51. The Republican Senate caucus can afford to lose two votes (assuming Democrats are healthy and have everyone show up). The 2016 ACA Repeal bill defunded Planned Parenthood and knocked out Medicaid Expansion. Either of those elements will cost the Republicans at least two votes. Combined, those two provisions probably cost the Republicans six to ten votes. That is a blocking coalition when combined with Democrats.

In the House, Speaker Ryan would like to pass anything with only Republican votes in order to not be hung out to dry like former Speaker Boehner (remember he has tough votes on the debt ceiling coming up). That means he needs 90% of his caucus on board with anything. The Republican House Freedom Caucus has enough members to deny Ryan a Republican only majority. The HFC is demanding a word for word replica of the 2016 bill.

This is a Big Biden Deal as the status quo bias works in our favor for the avalanche approach that I feared in November can’t get started. Long, boring committee meetings, calls to the CBO, wonks ripping apart a plan to help advocates find very sympathetic people to tell true stories with high emotional punch is where we’re going for anything more complicated than a technical correction bill or rebranding.

36 replies
  1. 1
    Chet says:

    So where is the pessimism index now?

  2. 2
    Another Scott says:

    “Passed” could mean several things in your title, and it’s not really clear that it goes with the rest of your post.

    tl;dr – Nothing “passed” except in the “ships passing in the night” sense, right?

    Ryan has to pass the 2016 HFC bill. The Senate won’t pass that, and instead is working on a “tweak/death of 1000 cuts” bill. Irreconcilable differences, so Donnie won’t get anything to sign that (fully) blows up Obamacare.

    Right?

    Thanks.

    Cheers,
    Scott.

  3. 3
    rikyrah says:

    This is what qualifies as positive news. I will take it, Mayhew.😃😃

  4. 4
    efgoldman says:

    Both you and Adam Silverman predicted something along these general lines, right after the election. I’m not sure I agreed with you. With even a minimally competent WH (instead of the total clusterfuck we have), they might have agreed on a program going forward.
    Of course the crook Price is in charge at DHS, and will be writing and rewriting non-statutory rules, certainly not to our advantage. But the legislation stands.

  5. 5
    Patricia Kayden says:

    Repeal and Replace or Repeal and Delay and Pray is dead.

    Good. But I assume Repubs will still try to kill the ACA by a million little cuts. They aren’t about giving less fortunate citizens access to healthcare. Not their thing,

  6. 6
    Ohio Mom says:

    As a special needs mom, my obsession has been the proposal to block-grant Medicaid. Where does that stand? I have a long list of personal worries I’d like to get back to.

  7. 7
    Sherparick says:

    Between the House Freedom Caucus and the Trump White House, about all we can hope is that they keep shooting themselves in the foot. What this also means is with ACA repeal locked up in the bowels of Congress, Medicaid Block grant and Medicare voucherization, two cherished ideas by the Dead-eyed Granny starver, A/K/A Speaker Ryan, are also blocked. Even the one thing that should unite Republicans, huge tax cuts for rich people and the corporations that they control may be blocked by the lack of consensus on the cuts, how to pay for them, and whether a “border adjustment tax or tariff or VAT” will be included in the mix.

  8. 8
    low-tech cyclist says:

    @Patricia Kayden:

    Good. But I assume Repubs will still try to kill the ACA by a million little cuts. They aren’t about giving less fortunate citizens access to healthcare. Not their thing,

    Absolutely true – this war is a long way from over. We’ll need to be riding those bastards all year, to make sure they’re at least as afraid of us as they are of their base.

    BUT this is genuinely good news, This means things are going to move a lot more slowly than we were bracing ourselves for. And that’s a blessed relief.

  9. 9
    Sherparick says:

    On the other hand, starting today, the Trump plan to trash the planet and eviscerate the EPA goes into full effect. It is reported that the Orange One will use the swearing in ceremony of Scott Pruitt as the Destroyer of EPA to sign a bunch of new EOs to vacate vehicle mileage standards, greenhouse gas regulation, and open all public lands to oil, gas, and coal extraction. Then he will fly off to Tampa for a MAGA rally with the yahoos of Tampa-St. Pete, yahoos who have houses and business only 10 the 30 feet above current sea level. http://www.politifact.com/flor.....tened-cli/ Ah, the learned stupidity and brain damage caused by watching Fox News and listening to Rush Blowhard.

  10. 10
    Weaselone says:

    It seems that even without legislation outright repealing ACA, that President Shitgibbon and the Congressional Contemptibles are more than capable of driving insurers from the marketplace through a combination of action, inaction and uncertainty. Exactly how does the ACA function if there are ultimately no insurers on the exchanges?

  11. 11
    ArchTeryx says:

    Yeah, this particular news means that my life, which might well be abruptly terminated if my Medicaid card quits working, may have bought itself a new lease after all.

    I’ve been following the debate over the Medicaid expansion closely on TPM. The non-expansion states don’t want to be “penalized” by funding the expansion states, and the (Republican) expansion states don’t want to lose all that filthy lucre that Medicaid Expansion brought to it. Roberts’ attempt to take the ACA down by allowing refusenik states and hoping that a Republican got elected President may have finally failed. I say “may” – my own pessimism index is still quite high, because the one thing they all agree on is the one thing that would kill Medicaid expansion dead – block granting. That would result in massive cuts in funding to expansion states, but the Republicans that run some of those expansion states seem fine with that so long as poor people get fucked.

  12. 12
    ArchTeryx says:

    @Weaselone: A better question to ask is, “How does the overall insurance market function when the individual insurance market collapses?”

    If the ACA is simply left a hollow shell of its former self, the individual market will rapidly collapse with it. That’s a minority of the overall market, but the knock-on effects might eventually take down the group markets with it.

  13. 13
    Barbara says:

    At this point, I would say that death by a thousand cuts is still an odds on favorite, much as I would like to believe something else, but Medicaid expansion is still the most important piece. Remember, they don’t want to just repeal expansion, they want to block grant the whole program. This is a catastrophic reduction in Medicaid funding. There are many, many problems with block grants but the one that falls most immediately on the doorstep of Congress is that it brings AARP into the picture because as many have noted before me, while the largest share of Medicaid beneficiaries are under the age of 65, Medicaid dollars go disproportionately — far disproportionately — to those who are over 65, as well as those who are under 65 but disabled. Quadriplegics, for instance. It will also end up pitting states that have a high share of elders against those that don’t. Pennsylvania, Arizona and Florida versus Louisiana, Mississippi and Texas. AARP has already been making noises.

  14. 14
    oldster says:

    As I said in an earlier thread, I wonder whether the HFC caused this or just responded to it.

    Is the Republican plan for gutting ACA going to fail because the HFC went maximalist?
    Or did they go maximalist because they saw it was going to fail anyhow, or eve because they were afraid of success?

    They may have realized that trying for repeal will be an ugly battle, and if they succeed then their own constituents will hate them, once they realize that “Obamacare” means the same thing that’s keeping them alive.

    By going maximalist in their demands, they get to posture as the Only True Conservatives, *and* they get to run against the tyranny of Obamacare year after year.

    This may have been a bus that they did not want to catch. Like Roe v. Wade, it is more valuable to them as a token hate-object, which ensures them a permanently riled-up base.

    Heaven forbid that they have to be honest with their constituents, or ever do some real governing.

  15. 15

    Why do we call it block granting? The massive cuts are the substance, block granting is just the delivery mechanism.

  16. 16
    ArchTeryx says:

    @oldster: Thing is, many of them may well go to their graves still hating Obamacare, but dead people don’t vote (and no Chicago jokes, please). They kill off a good portion of their own base, who’s going to be around to vote them in election after election?

  17. 17
    Ian G. says:

    The wall will never be built, ACA is never going away, and coal is never coming back. These are things that any Republican with half a brain understands, but that said halfway smart Republicans will continue to peddle to the Breitbart loons so that the pitchforks come out.

    On the Trump front, let’s hope he goes into permanent campaign mode, since he seems to enjoy that a lot more than the actual fucking job. The more time he spends wanking in front of adoring crowds, the less time he has to spend governing or signing bills.

  18. 18
    Barbara says:

    @oldster: I have read suggestions that the second is a clear possibility — that they can claim the mantle of repeal and go after those that would not go along with them. On the other hand, these are the people who probably really believe that nothing short of full repeal is acceptable. It can actually be both.

  19. 19
    rikyrah says:

    Republicans Can’t Keep Their Promises on Obamacare
    by Nancy LeTourneau
    February 15, 2017 4:23 PM

    I wish I had a dollar for every article I’ve read about the angst Republicans are feeling in their attempts to repeal and replace Obamacare. I might not be rich, but at least I’d have enough for a nice dinner out.

    The latest of this genre comes from some folks at Politico. And you’ll never guess who the Republicans are starting to blame for their dilemma.

    Republicans have reached a gut check moment: After spending more than six years vowing to fix the flagging patient that is Obamacare, it’s the GOP’s own repeal effort that’s on life support.

    Undoing the health care law despised by conservatives seemed to be a straightforward proposition for the party after it won the White House and retained control of both chambers of Congress. Instead, Republicans are sniping over how much of the law to scrap, what to replace it with and when. At this moment, it’s far from a sure thing any plan could get through Congress…

    It may take a direct intervention from Trump to get the party’s warring factions in line.

    “It’s hard to see how this gets done unless the president says, ‘OK, let’s do it this way,’” said Sen. Lamar Alexander (R-Tenn.), a key committee chairman on Obamacare.

    Yeah, the guy whose administration creates chaos out of everything it touches is going to save them. Puhleeze!

    For six years now the Republicans have been promising to repeal and replace Obamacare. Once they finally had the opportunity to make good on that promise, they heard from anxious/angry constituents about the prospect of losing their coverage. In response, they made another promise: that their replacement plan would be great and not cause any problems for those who were covered by Obamacare.

  20. 20
    Barbara says:

    @rikyrah: The guy who said that the replacement for the ACA was going to be unbelievably better and cheaper and then turned to Paul Ryan and said, “this guy has the details” when asked about it during some kind of press event? That guy?

  21. 21
    mai naem mobile says:

    I am guessing red state GOP senators have been hearing from their GOP governators. Forget the few red state Dem governators, it’s the Doug Douchebags,Gary Herberts and Brian Sandovals of the world who want to run for POTUS and don’t want to lose in their own states.

  22. 22
    Buskertype says:

    Anderson, I hope your right (and I put a lot of faith in your wisdom) but I’d be surprised if they don’t make this into more of a fight.
    On the other hand, if they were smart they might let it die quietly now while everyone’s distracted by Trump’s antics.
    I called my rep today and the lady at his office had no idea about the freedom caucus bill… I didn’t have the energy to point out that two weeks ago she promised me they were just about to reveal The Plan (TM)

  23. 23
    Mnemosyne says:

    Keep up the pressure. Keep calling. Keep sending letters.

  24. 24
    rikyrah says:

    @Barbara:

    ere are many, many problems with block grants but the one that falls most immediately on the doorstep of Congress is that it brings AARP into the picture because as many have noted before me, while the largest share of Medicaid beneficiaries are under the age of 65, Medicaid dollars go disproportionately — far disproportionately — to those who are over 65, as well as those who are under 65 but disabled

    .

    Say it again.

    The posterchild for Medicaid needs to be Bob and Jenny’s Grandma or Grandpa- THAT is where the $$$$$$$ go. Are Bob and Jenny ready for Grandma and/or Grandpa to live with THEM?

  25. 25
    gex says:

    My only quibble with this take is that Republicans happily vote for debt ceiling increases when they have the White House. I don’t expect that to be a tough vote. That $20+ billion wall isn’t going to be funded via tax increases after all.

  26. 26

    @oldster: I think it’s best to stop ascribing any sort of thought process to the HFC.

  27. 27
    Barbara says:

    @rikyrah: I think there are around 15 million “dual eligibles” nationwide. You get to dual eligibility one of two ways: You were already eligible for Medicaid and then turned 65, or, you were on Medicare and then you needed significant long term care that required you to spend down your assets, usually after you have entered a nursing home. While this is a large number of people, it’s only a little more than 25% of beneficiaries overall (there are around 54 million Medicare beneficiaries of all kinds), and they skew lower income. It would be good to enlighten people about who benefits from Medicaid, especially since many people still do not understand that Medicare does not cover nursing home costs. Nonetheless, a lot of people will still consider themselves immune from whatever happens to Medicaid. Not until the nearest emergency room is a two hour drive away because the local hospital folded will some people acknowledge any effect on themselves of whatever happens to Medicaid. And that will happen — it already has in areas of Georgia and Louisiana.

  28. 28
    Jim Parene says:

    @Sherparick: I have now lived in Fla. for 15 months.
    I love the weather, the wildlife, the Gulf fishing, Dali Museum, Sarasota eateries and arts and Mote Marine Laboratories.
    It is the people I find strange. The rednecks are ignorant and extremely fearful of things they don’t understand.
    The old folks are afraid of black people and “others”. The bible thumpers are aggressive and the “Deplorables” are loud, out and proud.
    If a Black Couple walk into a resteraunt in NYC, Boston, Albany, Chicago, SF, LA and any other civilized city, no big deal. Here, you see a great many looks in the couple’s direction.

  29. 29
    Jim Parene says:

    @Jim Parene: To clarify, I’m still flabbergasted that Floridians will gladly see the state underwater so long as it pisses off Libs and Eggheads.
    Wow.

  30. 30
    🌷 Martin says:

    Republican Senators realize they have an entirely different calculus than the House. They can repeal on the back of the budget bill with 50 votes, but they can’t implement a replacement with less than 60. They might have gotten Democrats to go soft on that 30 days ago, but that ship has long sailed and it’s never coming back. The House has no such constraint, so they keep plowing forward with their ideological right maintaining their demands. And then you have Trump just making nonsense promises on top of all of that. There is no point of complete overlap in that venn diagram. It’s never going to happen.

  31. 31
    Petorado says:

    Republicans seem to be realizing that there is no victory in victoriously crushing the ACA. It’s in their best interest to keep dragging this out and blaming Dems for locking it.

    The real win comes with continually stoking the fires of resentment from their base and championing ever greater purity among their ranks. Their strategy on the ACA now seems to be replaying what they did to general governance under Obama: find ways to make it work so poorly that in the next election voters will want to blow it up. The gamble is whether voters will buy that this national self-immolation is all the fault of Democrats when Republicans have a stranglehold on federal power, or whether Repubs finally get nailed to the wall for their malevolence and incompetence.

  32. 32
    Ohio Mom says:

    @Thoroughly Pizzled: I admit I do not fully admit the process through which Medicaid is funded; this is what I do know:
    Medicaid is currently a matching program. A state puts in X amount and the Feds match that amount. Some states get a one-to-one match, some states get more from the Feds (i.e., poor red ones).

    The totals can fluctuate with how much need exists in a state. As you probably already know, Medicaid pays for nursing home care for impoverished patients; living and medical for qualifying disabled (for an individual to live on a group home in my area costs between $30-40,000 a year); and health care for low-income citizens. Plus the ACA expansion.

    If a block-grant is substituted for the current matching system, the totals will not fluctuate. There will be a set amount from the Feds and that will be it. It will have small increases built in but they won’t keep up with inflation. If a state finds its Medicaid-qualified population increasing, well, too bad. The pie will have to be cut into smaller and smaller pieces.

    Block-granting is a ruse to cover cutting funding levels. The line is that it will give states more freedom to design their Medicaid programs — which they already have, different states have different eligibility requirements.

    The Medicaid population is a pretty powerless one, with the exception of nursing home owners. So Medicaid is vulnerable to being cut.

  33. 33
    Ethan says:

    @JimParene. Move to Key West. In Florida, the further North you go, the more Southern you get.

  34. 34
    Barbara says:

    @Ohio Mom: In the nether regions of my mind, I recall that Congress changed the formula so that the match could never be less than 50% and never more than 75%. Generally speaking, this disadvantaged poor states, but wealthier states finally prevailed for greater equity. Here is a map showing the 2017 matching level: http://kff.org/medicaid/state-.....percentage

  35. 35
    Barbara says:

    @Ohio Mom: Well, something happened to my first comment, so apologies if this ends up being a dupe. Basically, the match can never go below 50% and never above 75%, which was changed more than a decade ago (IIRC, which I might not). This was an improvement for wealthy states, which tend to cover more people (at a higher income level and in more categories). Here is a link to a map showing the variation for 2017: https://www.balloon-juice.com/2017/02/16/a-bfd-that-passed-amongst-the-chaos/#comment-6251301

  36. 36
    Bob Hertz says:

    Thanks again for your excellent posts, Dave. You and Charles Gaba at ACA Signups have the best ‘inside baseball’ on Congressional action, by far.

    I would be curious to know the demographics of where the Freedom Caucus firebrands come from. I have to assume that their districts are dominated by wealthy retirees and well-insured corprorate employees, plus some Rush Limbaugh-wingnuts.

    Otherwise, they are bound to run into at least some beneficiaries of Medicaid expansion and ACA subsidies…..like, in the real world.

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