Senate Majority Leader Mitch McConnell’s decision to delay his chamber’s vote on the Better Care Reconciliation Act (BCRA)—that being the Senate’s companion bill to the House’s repeal-and-replace bill—caused shock waves in Washington. Here are five takeaways:
1) Even now, don’t bet against McConnell.
The celebratory MSM headlines taking aim at the Kentuckian are coming fast and furious: “McConnell’s Reputation as a Master Tactician Takes a Hit,” “Vote Delayed as G.O.P. Struggles to Marshal Support for Health Care Bill,” “The Misery of Mitch McConnell,” — and that was just Wednesday’s New York Times.
Moreover, a latest poll on the Senate bill shows that 17 percent approve of BCRA and 55 percent disapprove. These findings, we can add, run parallel to other polls which have consistently shown low support for the GOP effort to repeal-and-replace/repair/rescue Obamacare. Indeed, the overall Republican effort seems to be the least popular piece of legislation in decades—less popular, even, than the 2008 bank bailout bill.
In the meantime, support for Obamacare itself has been rising; it’s now above 50 percent for the first time ever.
So it’s little wonder that some investment advisers are urging their clients to bet against passage of McConnell’s bill; just on Wednesday, came the news that Goldman Sachs is opining, “Our expectation is that the Senate will ultimately fail to pass broad health legislation.”
Yet at the same time, it’s worth recalling that the House version of this bill, the American Health Care Act, was seen as dead when it was pulled before a vote on March 24, and yet it was revived and passed on May 4.
So McConnell isn’t giving up. According to one behind-the scenes account in The Hill, McConnell, described by one admiring Senator as “the most even-keeled person,” told his colleagues that the “iterative process” on the bill would continue—but not forever. The Senate leader said that, soon enough, GOP lawmakers should come to an agreement: “We’re going to keep on talking, but we need to get an outcome and people need to engage.”
It’s that sort of cool deliberation that could enable McConnell to yet pull a victory out of his hat. In the rueful words of one Senate Democrat, Richard Blumenthal of Connecticut, “The mantra on our side is never to underestimate Mitch McConnell.”
2) The Republicans have let themselves get tangled up in a hard-to-win numbers game.
Once upon a time, a Republican could get up and talk about a bill in philosophical terms, without ever citing a score from the Congressional Budget Office (CBO). A GOPer could say as a matter of first principles, “I don’t think that health care is a proper responsibility of government.”
For example, the 1964 Republican platform, the document on which Barry Goldwater based his presidential candidacy, reads, “We Republicans shall first rely on the individual’s right and capacity to advance his own economic well-being, to control the fruits of his efforts and to plan his own and his family’s future.” Without a doubt, that’s an honest statement of a principled position, and as such, as a philosophical statement, it’s immune from numerical hairsplitting.
On the other hand, such a statement is not immune from political judgment. As the 1964 election results demonstrated, most Americans disagreed with the go-it-alone approach, and in fact, the Republicans lost resoundingly. The very next year, 1965, Congress enacted the Medicare and Medicaid programs.
Since then, most Republicans have taken the position that they support the general idea of achieving social-welfare goals such as health coverage, and yet they have a different, more businesslike, approach than the Democrats. This is a distinction not to be minimized; after all, the private sector knows a lot about innovation and efficiency, and it’s always true that any given program can be improved and/or streamlined. So if Republicans argue that they can do a better job of running a program and achieving its goals, the public is usually receptive to hearing them out.
Yet at the same time, if a Republican begins to make a technical, numbers-based argument—as opposed to the Goldwater-libertarian philosophical argument—then he or she must be braced for the inevitable counter-argument. That is, do the numbers add up? Is the Republican plan thought through? Is it really superior?
Just on Sunday, Health and Human Services Secretary Tom Price sounded confident about his argument as he declared on CNN:
The system, the plan that we would put in place, would not allow individuals to fall through the cracks. We would not pull the rug out from under anybody. We would not have individuals lose coverage that they want for themselves and for their family. We want to make certain that health care is available to all Americans.
We can note that Price made a series of definitive statements about the fate of the insured and uninsured—and each of them, of course, was closely scrutinized for accuracy. Thus the battle was joined: factual assertion vs. factual assertion.
Unfortunately for Price, the next day, CBO released its score of BCRA, and found that the number of uninsured would jump by 22 million—including 15 million in the next year.
Many Republican politicians and healthcare analysts hotly dispute CBO’s methodology—but not all. House Speaker Paul Ryan, for instance, defends the legitimacy of CBO’s scoring process, if not necessarily the precise number. Moreover, Ryan recalled, back in 2015, he was joined by the same Tom Price—then the chairman of the House Budget Committee—to help select the budget agency’s new director, a Republican.
So we can see: If top Republicans wish to live by CBO numbers, then, they must be prepared to live with them. If the political battle is defined as a numbers game—that is, a battle over the number of uninsured—then Republicans must use great care in assembling legislation that makes their numbers better than the Democrats’.
3) In their zeal to attack Obamacare, Republicans might have overlooked their best argument.
The irony of the Affordable Care Act is that despite all its grand promises of universal coverage, it was a failure—on its own terms. Even at its high-water mark, in late 2016, Obamacare had still left 27 million Americans uninsured.
So if Republicans had wanted to, they could have told the American people, “The Democrats didn’t do what they said they’d do. So now let us do better. We won’t let 27 million people fall through the cracks.”
Of course, at the same time, the GOP could have said that their better alternative would be run according to conservative, no-nonsense principles. The Republicans could have emphasized that their approach would forbid spending government money on activities that shock the conscience or common sense. For instance, the GOP could have pledged that Uncle Sam would no longer be paying for abortions, sex-change operations, hair transplants, and so on.
In addition, Republicans could have recommitted themselves to rooting out Medicaid fraud, which, according to a report from the Government Accountability Office, costs the feds $17.5 billion a year–although other cost estimates go far higher.
Admittedly, such GOP reformism applied to existing programs would not have challenged the idea of national health insurance, and so purist ideologues on the right would not be much interested in such technocratic pursuits. Yet as we have seen, since the 1960s, for the Party as a whole, the goal has been to address the problem—but to do it at less cost and with more effectiveness. And with such an approach, hardcore Republicans would still be happy to see GOP leaders pushing hard to de-fund obvious atrocities and stupidities, while centrists would be reassured that the health programs are being fixed, not junked.
4) The Republicans already have a model for healthcare reform—the recent changes at the Department of Veterans Affairs.
The former Veterans Administration, founded in 1930, rates as an old-line agency, for sure, even if its mission, of course, is enduring. Yet unfortunately, as even a casual news consumer knows, the venerable agency has been regularly rocked by scandals, including a major eruption in 2014 that forced the resignation of Barack Obama’s VA Secretary, Eric Shinseki.
We might note that the VA spends nearly $200 billion a year, and that the healthcare portion of the agency can be described as not just “single payer,” but “single provider.” The government pays for bricks-and-mortar facilities across the country, to which vets go to receive treatment. In other words, the VA system is about as pure a form of national health insurance as one could find.
Yet at the same time, this statist system, scandal-plagued as it might have been, is plainly not going anywhere. To be sure, over the years, some have suggested that the VA be privatized and that veterans simply be given healthcare vouchers for their needs. Such suggestions have never amounted to anything, in part because veterans groups are adamantly opposed.
As a result, following the principle that politics is the art of the possible, shrewd Republicans have focused on reform, as opposed to revolution.
Let’s let former House Speaker Newt Gingrich describe what reform at the VA looks like today; specifically, let’s look at the work of Dr. David Shulkin, President Trump’s new pick to lead the Department:
Shulkin has helped implement a VA Office of Accountability and Whistleblower Protection, created a website to track and publish wait times at every VA hospital, drastically increased mental health services across the system, and developed a way to electronically transfer veterans’ medical records from the Department of Defense to the VA to simplify their transition from service to civilian life. Each one of these accomplishments is remarkable.
In addition, on June 24, Trump signed the Veterans Accountability and Whistleblower Protection Act, which Gingrich describes as “the next great breakthrough for VA reform.” The bill is Republican good government to the max: It will empower of the VA Secretary to quickly remove, and otherwise discipline, underperforming VA managers. As Trump said as he signed the legislation, “We will not rest until the job [of reform] is 100 percent complete for our great veterans.”
Here we might pause to make a further point about politics and the art of the possible: Most Democrats, too, were in favor of the new reforms. Even though the legislation was strongly opposed by federal employee groups, the pressure on pols in the wake of the scandals was so strong that it passed the House by a margin of 366-55, including 137 Democratic votes. And the Senate passed the bill by a voice vote—which is to say, an overwhelming majority.
Thus we can see: Even now, amidst all the partisan rancor, it’s still possible to pull together big bipartisan majorities for positive action—even action of a decidedly Republican hue. Yes, it took the tragedy of the scandals to provide the impetus, but Congressional Republicans were skillful as they guided the legislation to passage; it was always pitched as a technical reform issue, not an ideological watershed.
And yet as they say, there’s nothing so powerful as an idea whose time has come. So now Shulkin has a strong mandate to keep pushing forward.
Indeed, even today, the VA reforms are very much top-of-mind at the White House.
During Tuesday’s White House press briefing, deputy press secretary Sarah Huckabee Sanders made a point, in her opening statement, of calling attention to the “historic” accomplishment of the VA bill. And if the press wasn’t interested—all the journos’ questions went to other topics—well, plenty of people across the country are extremely interested in VA reform.
So we can say: Score one for Republican-style governance. Of course, we shouldn’t minimize the difficulty of VA reform, just as we shouldn’t minimize the difficulty of any other kind of reform. Still, would-be Obamacare reformers might take some political pointers from the VA experience: Swing-voting middle Americans aren’t much interested in high ideological principles—they just want things to work.
5) Medical science is a proven way to make healthcare better and cheaper; unfortunately, in the current debate, we haven’t been hearing about it.
For years now, leaders in both parties have been saying that they would make health care more affordable—by which, of course, they meant make health insurance more affordable.
Yet it never seems to happen. So why not? Perhaps because there’s a big difference between health insurance and health itself: One is, in effect, a promissory note in the event of ill health, and the other is the reality of being healthy—or not. And if people aren’t healthy, then, by definition, health costs will be high, and health insurance will be expensive.
To further illustrate this distinction, we might consider a diagnosis of Alzheimer’s Disease (AD). Today, there’s no cure for the dreaded AD, and this absence makes something of a mockery of health insurance. Yes, it’s nice if health insurance is there to cover the cost of care for dementia and the like, but at present, there’s no hope for a cure, and so the insurance only goes to cover a sometimes long decline.
Indeed, the annual cost to the nation of AD, according to the Alzheimer’s Association, is $259 billion. We can quickly see: No matter who’s footing the bill—public, private—the cost for all that care is staggering, and it’s continuing to rise as the population ages.
So wouldn’t it be nice if we had a cure for AD, or even a treatment that could significantly alleviate its symptoms, and thus decrease its costs? And if such a treatment were in hand, and people were living better, wouldn’t it be nice if we could then consider raising retirement ages, thus removing fiscal pressures on our entitlement programs, including Social Security?
All that could be possible, but only if we have improved medical science—that is, better treatments.
We can look back at our own history and see how this has worked in the past: If we can make a disease go away, it saves not only lives, but money. Polio was once a major killer and crippler; moreover, people confined to wheelchairs and iron lungs for the rest of their lives were not cheap to care for. Yet now, thanks to the Salk and Sabin vaccines, polio is a distant memory, and America is blessed with a lot more human resources—and money—as a result.
We can cite other instances, too, where better science has improved lives, saved lives—and cut costs. For instance, when scientists figured out that most stomach ulcers were caused by a bacteria that could be cured by simple antibiotics, long cycles of painful and ineffective treatment for ulcers were eliminated. Similarly, when it was discovered that the risk of heart disease could be lessened by the simple method of taking aspirin and garlic every day, the human and societal costs of heart disease fell dramatically.
The point about the value of better science is, seemingly, obvious. And the same can be said about the value of technology, the handmaiden of science. This is the story of the rapid advances of our civilization in the last two centuries; it’s the railroad, the assembly line, and Moore’s Law—to name just three major advances—that have made just about everything not only much cheaper, but also much better
Interestingly, President Trump touched on this point in his January 20 Inaugural Address, when he pledged that he would work “to free the Earth from the miseries of disease.” And yet unfortunately, not much has been heard of the idea since. Indeed, his administration has actually proposed cuts in funding for the National Institutes of Health—although Congress has already overridden some of them.
To be sure, it’s not proper to think that only a government agency can foster more and better medical science—but somebody has to. And yet unfortunately, nobody in Washington today is picking up where the 21st Century Cures Act, spearheaded in the last session of Congress by Rep. Fred Upton (R-MI) and Sen. Roger Wicker (R-MS), left off. That bill was a big step in the right direction, but it was only a step. Until there’s the same sort of riotous innovation in health care that we are seeing in AI or robotics, we will know that more steps are needed.
If that sounds like a daunting burden for healthcare policymakers, well, that’s because it is. But then, the challenge of #Winning is always daunting. And winning sure beats losing.