Sen. Orrin Hatch, Republican of Utah, had a simple explanation for the lack of committee hearings in the Senate on a major bill to replace the Affordable Care Act, the "discussion draft" of which was finally revealed yesterday: “We have zero cooperation from the Democrats,” he said, according to the Los Angeles Times. “So getting it in public gives them a chance to get up and scream.”
Just about everyone is sick of the partisan rancor that radiates from Washington and now flares up in the most unwelcome places, from subway trains to church parking lots. But the chance to “get up and scream” is inseparable from the democratic process. Crafting legislation behind closed doors is admission not only that the legislative system is broken but that political leaders have no interest in repairing it.
Politics is the art of the possible—but on health care, our politicians keep settling for the possibility of narrow, partisan victories.
The Republican drive to replace the Affordable Care Act with a bill that the U.S. bishops say will “wreak havoc on low-income families and struggling communities” has been distinguished by an almost complete lack of public input from those with a working knowledge of health care—which means there has been almost no attempt to inform or educate the voters who will ostensibly pass a verdict on this Congress’s work next year. But this is not a sudden change in the way Washington works. Julie Rovner of Kaiser Health News, who has been covering the never-ending attempts to reform health care for more than 30 years, recently marveled at “Congress’s slow, stuttering retreat from...transparency.” And the Washington Post’s Glenn Kessler writes that Democrats’ push to pass Obamacare in 2009 featured a floor debate “mostly for show.” Like earlier efforts during the Clinton administration, the real crafting of the legislation was done behind closed doors. By this reasoning, Senate Majority Leader Mitch McConnell, who has been startlingly upfront about how everything has been pushed backstage this time around, has simply “skipped the preliminaries.”
Mr. McConnell’s stated intention to force a vote on the Senate bill only a few days after its unveiling—putting a maximum distance between the vote and next year’s congressional elections—only underscores the normalization of power politics as a substitute for public debate. By choking off adequate funding for Medicaid, which now serves about one-fifth of the U.S. population, the legislation would constitute “the largest single reduction in a social insurance program in our nation’s history,” as three health care experts recently wrote in The New York Times. Yet the wisdom of such a drastic move has barely been discussed in the halls of Congress, let alone in the increasingly scarce town meetings held by members in their home districts.
Politics is the art of the possible—but on health care, our politicians keep settling for the possibility of narrow, partisan victories in Congress rather than workable, long-range solutions to worsening problems such as rising costs and inadequate insurance coverage. Americans are united in dissatisfaction with our healthcare system but almost intractably divided over potential fixes. Both that level of division and the needs of the tens of millions whose access to health care is at stake demand that both legislators and voters struggle with this issue in public until we can achieve something much better, especially for the most vulnerable members of society.
Correction: An earlier version of this story referred to the American Health Care Act, which was the name of the bill passed by the U.S. House on May 4. The Senate version of this legislation is called the Better Care Reconciliation Act of 2017.
The health care debate is one of those social phenomena in which almost everyone who has an opinion, with the possible exception of those who are unable to get beyond everyday snark, has a valid contribution and insight. The subject has so many facets and affects the vital interests of so many people that hardly an opinion gets written that does not contain an interesting point. One area that might make a greater contribution to the discussion than it has made so far is health information as it relates to free market efficiency.
The relative lack of congressional attention to operational impediments to potential free market efficiencies from use of data based decision support in the health care industry is astonishing. It might be due to what could be called the “cultural drag” of status quo thinking. The impediments at issue are information impediments. Remembering our old courses in economics and finance, we recall that a fundamental assumption concerning market efficiency is that all participants, both on the demand and supply side, have all of the necessary information on which to make economically rational decisions. The assumption is actually a two-part premise, first, that necessary information is freely available, and second, that it will be acted upon rationally. In the securities markets, even though well- publicized lapses have occurred, law and regulatory enforcement have worked pretty well to enable investors to make rational decisions (if they were rational and financially literate in the first place). In health care, secrecy and information hiding abounds in many areas, especially as relates to pricing, professional competence and efficacy.
This general subject has been studied by numerous entities but has not been the subject of comprehensive legislative proposals for some time. A good summary of the situation published recently can be found at https://www.foreignaffairs.com/articles/2017-06-13/right-way-reform-health-care 6/22/17. One thing that is not often talked about in this connection is the difficulty of incorporating data from clinical practitioners into the overall storehouse of data that could be useful in formulating performance and cost control incentives. This and other challenging problems are hardly ever discussed in a context other than a fee for service context. Some experimental approaches were part of the ACA and hopefully more progress can be made toward the greater contribution potential of information for health care efficiency and cost control in future legislation.
RE: 'an almost complete lack of public input from those with a working knowledge of health care"
You're kidding. Remember the ObamaCare package that the members of Congress had not had a chance to read (much less we voters) but voted on anyway?
Editors,
I am sorry but this is just pure democracy in action, not closing the door to democracy. The Democrats will not cooperate so why include them. The Republicans were invited to the White House by Obama and stated their objections to the ACA. Their objections were dismissed and consequently the Republicans didn't vote for it. Why vote for something that cannot work and hasn't?
The Democrats were invited to participate in the healthcare discussions. They have formed what is called "The Resistance" and this is playing out each day for all to see. The vitriol coming from Democrats is amazing. But not a peep from the editors on this un-American and un-professional behavior and definitely un-Catholic behavior. It is one thing to object to any legislative approach it is quite the opposite to constantly undermine everything. Is it a mean bill as President Obama says? Hillary Clinton called the Republicans, the "Death Party." Elizabeth Warren calls it "Blood Money." Is it? This is a week after one of their zealots tried to kill several Republican congressmen.
The healthcare bill if it ever gets passed will go to the ultimate jury, the people. These judges will vote in a year and a half and then again in another two years. If they don't like what they see then the originators of this healthcare approach will be replaced by the people who gave us the unsustainable health care act now in operation. Is this what the editors want? Or do they sense that the Republicans might have a viable approach and that is the real fear, the people they constantly criticize may govern effectively while the people they endorse cannot govern.
In the mean time, the editors have no idea what the problems of healthcare are. They are certainly not laid out in America for its readers to see. For example, no one will be deprived of health insurance or access to healthcare but that is not what one reads in America. So the editors must be mis-informed. Right now access to good healthcare is minimal for the poor (under their preferred solution) and many non-poor cannot afford what is available. The Senate bill is trying to repair that. For that we get histrionics about Republican depriving the poor when what they are doing is just the opposite.
All the editors seem to be doing is resisting. Until the editors here take a different approach, the best they can be thought of are obstructionists to attempts to repair dysfunctional programs the Democrats have implemented.
Editors
You have remarkably short or selective memories.....The best example: Harry Reid determined to pass Obamacare before Christmas 2009. The result was a 2,700 page bill that every Democrat admits he had not read. It was expected that by the time it got into reconciliation with the House Bill, changes would be made and anew vote taken on the revised bill. But Scott Brown did the unthinkable and won Ted Kennedy's seat making a future vote to amend a disaster since he ran on being the 41st vote against the ACA. So no one having read the bill Nancy Pelosi and Harry Reid cooked up a process whereby the House would pass the Senate version by amending a prior passed-bill number stripped of its content with the Senate ACA bill into place.... The infamous "deemed passed" approach. In turn Harry Reid made up a new rule called the Reconciliation Rule that said you only need 51 votes to pass items only effecting the budget and thereby could repass the reconciled bill with just 51 votes and thereby avoid Scott Brown enforcing the filibuster. Dem Rep Alcee Hastings noted "we are making up the rules as we go along"
I pass over the fact that the rules of the so called ACA debate provided that no amendments could be offered....As if that would even be possible with a 2,700 page bill no one was given a chance to read. No one seems to have any idea of how many thousand ACA regulations were issued by the Dept of Health and Human Services and the IRS.
Hard to believe that the 2,700 page ACA which effected 20% + of our economy and all of our lives was passed without being read! Nancy Pelosi correctly analyzed it "You have to pass the bill before you can see what's in it..."
Compared to this prior fiasco the current proposed Republican legislation is a model of democratic transparency at some 145 pages that everyone will have time to read. I note that the critiques started well before its publication yesterday.
ACA relied , as Dr Gruber inadvertently reminded us, on its lack of any semblance of transparency and "the stupidity of the American Public"
So which approach is more democratic?
So Obamacare created behind closed doors with partisan insistence that "we must pass the bill to see what's in it" or you'll never hold office in the Democratic party again, represents democracy? How long will the editors of America and our economically illiterate bishops keep kissing the feet of the party of death while calling the practice Christian?
what a disappointing group of comments. The usual party line from Cosgrove. there is no democracy in action by passing important legislation like this by reconciliation, with no hearings or debate. Contrast that with the ACA and the plethora of hearings and debate. see the following: https://thinkprogress.org/orrin-hatch-trumpcare-reconciliation-a2bf7ebdb902. It is appalling how many commenters sound like they never read the sermon on the mount or are unable to accept it's call. Too bad the editors of America in offering up their pablum don't get down to brass tacks with their readers and tell them what that message is.
The ACA was passed by Reconciliation.....That is why it can be repealed by Reconciliation! Harry Reid invented the Reconciliation Rule to reduce the vote to 51 to avoid Scott Brown's unanticipated election
Mr. Heyman,
Please don't quote the sermon on the mount to defend anything the Democrats have done or to oppose those who point out their dysfunctional policies. One has only to look at the African American community in the United States to see the devastation that Democratic policies have brought to them. If this is what you believe the sermon on the mount brings, then I am afraid that your understanding of it is misplaced.
The ACA is another dysfunctional Democratic party program that has wrecked havoc on the country and the Republicans are trying to correct it. I suggest you read what they are trying to do from impartial sources before issuing any condemnations on those who support their efforts to correct a bad situation.
The alleged widespread dysfunction and devastation due to democratic policies hasn’t stopped Californian’s life expectancy exceeding that of all twenty-eight right-to-work states.
Please comment on how the democrat mayors in the nation’s five largest cities with six per cent of the nation’s population, account for twenty percent of the nation’s GDP.
Google: bloomberg + sanctuary cities already great
Dear Editors,
You are correct about Trump care.
Obamacare however, was no better. I can give horrific examples of individual poor people on Aid whom I accompanied to their provider. The provider was disgusting. And the only other three who also took the poor people's Obamacare were equally disgusting. The poor under Medicaid had limited and disgusting options for healthcare. They were exploited for the payment the provider would get. Maybe getting rid of Medicaid is a good thing.
Why don't the Jesuits give up their healthcare insurance? Refuse to buy it for all Jesuit until all people in this country have good healthcare, most especially the poor?
The poor people skew the actuarial tables for the worse because statistically they die young and have higher healthcare costs. Well so would all of us if we had bad or no food, lived in crime areas, had not clean water, etc. And the insurance companies depend on actuarial tables to predict their costs. So they say the poor costs everybody more money. I say throw out the actuarial tables. Throw out the insurance companies. Let's all get together, allow the rich to "adopt" poor people and pay for their insurance.
Katherine
In reply to Mr. Meisenzahl, a half truth is as bad as a lie. you ignore the fact that the ACA was extensively debated in the House and Senate before passage. Senators and Representatives had an opportunity to offer amendments before the bill was signed by the President in March of 2010 over a year after the bill was first introduced. Contrast that with the back room bill offered up by McConnell and his 12 dwarfs. Neither you , Mr. Cosgrove, nor ms. Marsh offer any refutation of the affect of the changes on the existing policyholders with more than 20 plus million losing coverage over the decade.
In reply to Mr. Cosgrove, I did not know you were yet again an expert on the problems of the African- American community. That community and poor whites and Latinos will be seriously affected by the repeal of the ACA. And yes I have read and read again the sermon on the mount. I don't pretend that the democratic party has all the solutions to the problems of poverty, homelessness, criminal justice or climate control. But one thing is for sure Neither Donald Trump, Paul Ryan or Mitch McConnell have any plans to solve these problems but are working hard to make them worse. Plain and simple the repeal of the ACA is intended to fund massive tax cuts for the welfare while removing the taxes collected under the ACA to give it the programs necessary to a comprehensive health policy. Yes I do read neutral reviewers . It's called the CBO not Forbes articles the publication of the rich and ridiculous.
Please see Politifact March 16,2017 ...basically the only amendments to ACA allowed were technical and a final one that was shoved down the democrats throat by publicity: forced congressional participation in the ACA. The original bill exempted the Congress and its immeadiate staff and subsequently a whole new subsidy was constructed to keep them from being hurt by the ACA as others were. Democrats could not take the heat for their own exemption and finally cosponsored the amendment.
Reconciliation was adopted by Harry and Nancy because the Bill could not pass without Scott Brown's vote. The House Bill was abandoned and any related debate became irrelevant as described above. Once again I wish to point out that the ACA is a 2700 page bill and everyone who voted "yes" admits they had never read the Bill! Please contrast that with a 145 page Bill you yourself are now capable of reading.......did you read the ACA? Let's not even get into the 20,000 pages of HHS and IRS interpretations that subsequently were made up whole cloth or the exemptions created after the fact. The issue presented in the Article was "Closing the Door to Democracy" . If you determine that the current Republican approach lacks the elements of democracy, then I ask you: what does it mean democratically if everyone who voted for the ACA never even read their own Bill? ACA is 20,000 pages of rules and regulations on top of a 2700 page bill......Democracy in action ?
As to the CBO estimate on "lost coverage" I ask you to compare it to their prognostications on the ACA where they over estimated participation by more than 100% and underestimated costs by 300%. Infact that cost screw up was demonstrated in the first three years which by then had incurred added administrative costs that totaled $2.75 Trillion vs their estimate of $980 billion for 10 years! (See CNBC March 13 2015 based on Centers for Medicare and Medicaid reports)
I take the CBO estimates as generally being highly suspect. Certainly recent history shows that a very healthy skepticism is a prudent way to view their work.
By the time the ACA collapses it will have been about a $4 Trillion disaster.
Mr. Heyman
I have read a great deal about it. That doesn't make me an expert but in the 1930's the illegitimacy rate amongst blacks was the same as the white population. By the 1960's it was in the high 20% and now is over 70%. I would look to that as the cause of the dysfunction in the black community and the high crime rates. This has nothing to do with healthcare but was pointed out to show that Democratic policies have caused poor outcomes just as the ACA has led to poor outcomes. None of which the Democrats will ever own up to.
We can disagree on this. One thing I have learned from the politics of the last 30 years is that one side creates the problems and the other side gets blamed when it cannot correct the problems the other side has caused. The Republicans are trying to lower the cost of health insurance so that it is more affordable. As it is now many who sign up for the ACA pay huge premiums that then have huge deductibles so they are getting anything but inexpensive healthcare. They are essentially paying a large cost for catastrophic insurance. Republicans are trying to stop this insanity. To deny what the Republicans are trying to do is at best disingenuous but in reality dishonest. The editors have never once covered this issue honestly.
Whether the Republicans can reduce health insurance costs is a good question. But one thing for sure is that Democrats will not try to help them and have caused the costs to rise.
I have no idea what you mean by this but if you are implying that the Republicans are trying to reduce the deficit, they are guilty as charged.
If you mean that they are trying to provide tax cuts for the rich, then that is nonsense. This is what Obama and the senate Democrats are pushing. The rich do not make a large part of the voter base so why cater to them and secondly they do not vote for Republicans. Obviously some do but more vote for Democrats than Republicans. So anyone including Obama and senate Democrats who accuses the Republicans of providing tax cuts for the rich are being dishonest since that is not a Republican voter base and a primary source of donations.
Also I would not try to make others look like bad Catholics while trying to imply that you are a better one.
“…Democratic policies have caused poor outcomes…”
Perhaps you could note the names of several major cities or states where republicans have had better outcomes.
Seattle has the only $15/hour minimum wage in the U.S. Seattle also has the lowest unwed birth rate of the seventy-five largest U.S. cities. Perhaps the U.S. unwed birthrate would mimic Seattle’s unwed birth rate with a federal $15/hour minimum wage. Forty percent of all children in the United States were born to unmarried mothers in 2014.
Chuck Seattle does not now have a$15 min wage.....itis rising in increments to $15 over 3 to 7 years since enacted depending the number of employees and benefits paid. Only employers of over 500"employees have to pay $15 in 2017
I believe that your attempted correlation with wedlock births is misplaced based on this fact alone.
But now add the news yesterday that the scheduled increases to date (not at $15 yet) have already killed off some 5,000 jobs and reduced hours ( university of Washington Report). The same report computes the loss/benefit of the Seattle minimum wage law at 3 to 1 (losses to benefit). So 3 people are hurt for every 1 person benefited! And the law isn't even fully implemented! It contradicts a UCal Berkley report that only covered the restaurant industry. See New York Times June 26 2017
A future $15/hour minimum wage perhaps gives people confidence financially to plan married life.
Seattle’s economy apparently survived 5,000 “lost” restaurant jobs as Seattle’s unemployment rate has fallen below four percent.
Chuck
A 3 to 1 loss to benefit is net! All the full employment numbers in Seattle prove is that market forces would have caused a wage increase for restaurant workers if economically supportable. Note: the U of Wash Report didn't limit itself to restaurants and all of the legislated increases have not even taken affect yet....restaurant effect is in not even halfway to the full $15 (2021) and negative effect has just started.
A loss of all low pay Seattle restaurant jobs perhaps would yield zero Seattle unemployment and zero Seattle unwed births.
I would like to thank Mr. Kotlarz reply to Mr. Cosgrove's comment on the poor outcomes of democratic policies. Mr. Cosgrove's comments regarding the African-American community are offensive for too many reasons to enumerate. It is worth noting that between 1960 and 2016 the democrats and republicans have each held the White House 28 of those 56 years. the comments ignores the racism in hiring practices, the disproportional mass incarceration explosion of blacks to whites due to inequities in our criminal justice system.
Also, as I stated the House and Senate bills are intended to give a huge tax cut to those who have unearned income of 200 to 250K and above in unearned income. Mr. Meisenzahl's revered Politifact blog notes that 33 billion would be saved by the 400 highest income people and proportionally down the line to the top 20% that have unearned income of 200 to 250 K over the decade. http://www.politifact.com/truth-o-meter/statements/2017/jun/26/barack-obama/obama-blasts-gop-senate-bill-tax-cut-rich-health-c/. Warren Buffett has noted that in the first year of the ACA he would save 630K in taxes. The CBO report lays out the inequities in healthcare coverage that will occur.http://www.npr.org/sections/health-shots/2017/06/27/534465505/chart-cbo-weighs-who-wins-who-loses-with-senate-health-care-bill. The bottom line is that the Senate bill is trickle down economics of the Republicans in the healthcare area.
Finally as to Mr. Cosgrove's assertion I tried to make others look like bad Catholics that was not my intent. I simply repeat that a bill that is so heavily balanced against the poor fials the Sermon on the Mount test. If the shoe fits wear it. I wake up everyday realizing that I am a failing Christian needing to do better. Try it!
Thomas
The topic of the Article was not the value/lack of value in the Republican Bill , now pending and bring modified as I write.
The topic of the Article was "Closing the door to Democracy" . You took the position that the ACA was a model of democratic process which I disputed citing the admission of everyone voting for The ACA that they never even read that 2700 page monstrosity; and there were a subsequent 20,000 pages of rules and regulations and exemptions that no one saw or voted on before they were summarily implemented.
I noted that the current Bill is about 145 pages and everyone has read or is reading it, with the amendment process to be opened on the Senate floor next week.
You have abandoned that topic in favor of a comparative analysis of a bill not yet even voted upon. While you are doing that analysis I suggest you google and read up on the quality of care afforded by the ACA expanded Medicaid program. If you aren't shocked, then just note that visits to Emergency Rooms increased dramatically after the expansion (contrary to all CBO and other projections) precisely because it was better care than received under the medical networks which accepted Medicaid. The Catholic Hospital Association wants to keep that expansion so that they get some payment for Emergency Room Services via Medicaid whereas without it the law required them to provide the service and take the loss. In short health care will not be cut off without the ACA Medicaid but some reimbursement will be! The expanded Medicaid population accounted for well over half of the increase in the insured under the ACA
As to Warren Buffet....please do a bit of research: he has structured most of his income as dividend income not subject to FICA or withholding and it is taxed at dividend rates which are half or less of a salary tax rate. He has also created a foundation through which he is channeling all of his billions to be spent through the Gates Foundation. When asked why he was going to such lengths to avoid the Federal Inheritance tax, Warren responded that he thought the Gates Foundation knew better how to spend that money than the Federal Government. Warren is the epitome of the "verbal noblesse oblige billionaire" .
Secretly drafting a bill to "reform" the healthcare industry is not democratic in and of itself. Keeping the bill secret even from most Republican senators is bizarre. The reason for secrecy was obvious once it was released - it stunk to high heaven. It would deprive millions of healthcare coverage in order to give a tax break to the richest people in the country. A one-word description of this kind of greed and cruelty is "sinful."
Blathering about political processes in the past is nothing but a distraction. It is in the past, a sunk cost that is irrelevant to current decision-making. If it was wrong, the process needs to be improved. The Trump administration is the most corrupt and incompetent administration I have ever witnessed and the Republican party is complicit in allowing wrongdoing to continue without restrictions or oversight. Both Trump and the Republican party are scary in their willingness to ignore laws, the Constitution and their moral obligation to represent the citizens of the USA. This Senate bill on healthcare is only one part of the overall picture.
Lisa
Secret?.....give me a break ....the entire Trump Campaign was at least 30% based on doing exactly what is being done, albeit being done less radically than originally proposed. I know you are shocked and stunned by the election result but you can hardly be surprised by the attempted fulfillment of this fundamental campaign promise. The thrust of this article by the Editors is that the Republicans and Trump are acting undemocratically ......the response has been that the Editors are hypocrites on this point in that they raised no such dire alarms when the democrats acted far more undemocratically .....No one who voted for the ACA is able to say they first read that 2700 page monstrosity! That Lisa is the very essence of acting undemocratically ...unthinking political obedience is a betrayal of basic responsibility one is elected to undertake.
I think the Editors have selected memory. When ObamaCare was being proposed it was behind closed doors among the Democrats. Their initial requests for Republican input was both phony and disingenuous. Reid and Pelosi forced through a 2700 page healthcare bill that nobody read but all Democrats voted for. It was obvious to any senior consultant in the healthcare benefits consulting industry that the CBO significantly underestimated the costs and overestimated savings. The initial costs were about $900 billion but three years later the costs were re-estimated by the CBO to $2.7 Trillion.
What is so "Democratic" about that?
The Republican proposal is flawed as well and Washington politics is the problem. Many in the Catholic Church would prefer universal government paid healthcare benefits for all Americans. However, the costs would bankrupt our nation. You can tax the .1% all you like and it will not cover the increase in costs of government paid universal healthcare. Once enacted, government paid healthcare would be like trying to stop a speeding train without brakes.
The truth is that some pain and suffering will have to be accepted in any national health insurance proposal to replace ObamaCare. I am not certain that Congress (e.g., Democrats and Republicans) can reach the best compromise for the good of the people. We need leadership and not politics as usual.