Christopher Baum and Alan
Maass report on the collapse of the Republicans' anti-Obamacare crusade--and
explain why the health care crisis will persist anyway.
July 28, 2017
THE LONG-cherished Republican
dream of repealing and replacing Barack Obama's Affordable Care Act (ACA) has
been dashed on the floor of the U.S. Senate.
Late Thursday night, after
weeks of trying and failing, Senate Republicans thought they would be able to
eke out a majority vote for legislation that would have partially repealed the
ACA--even though a number of Republicans said publicly that the measure was so
inadequate they didn't want it to become law.
But in a dramatic last-minute
twist, John McCain cast the deciding vote for a 49 to 51 defeat of the
Republicans' last real hope of keeping their anti-ACA crusade alive, at least
for now.
Ironically, McCain had
returned to Washington two days before from treatment for brain cancer to cast
the deciding vote to open debate on health care legislation, giving Senate
Majority Leader Mitch McConnell a reason to hope that victory in some form was at
hand.
But McConnell never won
another vote to actually pass a health care measure.
After defeats on more
substantial "repeal and replace" proposals and even a simple
"repeal only" of the ACA, the Republicans were ready to settle for a
so-called "skinny" repeal proposal that would have eliminated some of
the most unpopular ACA measures--but whose main purpose was to throw the whole
mess back to a "conference committee" of Republicans from the House
and Senate to try again for another compromise.
Then McCain jumped ship, and
the GOP's "repeal and destroy" mission fell apart.
It was a humiliating fiasco
for Republicans--and a victory for those who stood up to the GOP's attempt to
further harm health care for working people and the poor in order to hand out tax
breaks to the rich.
But even so, some difficult
truths need to be acknowledged: Even without a new health care law, Donald
Trump and the Republicans are still in a position to inflict damage on an
ailing system--a system that is already drifting deeper into crisis, regardless
of what Republicans do.
That's because the ACA--far
from achieving its goal of providing affordable coverage to all, or close to
all, Americans--has made health care more expensive, chaotic and inaccessible
in many important ways. Obamacare, by preserving the for-profit character of
health care in the U.S., set the stage for a more vicious assault to come.
Trumpcare may be doomed for
now, but the ACA status quo is still a disaster. We need a movement that not
only protests what we don't want, but puts forward what we do: an expanded
Medicare-for-all, single-payer system.
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AFTER YEARS of symbolic bills
that they knew would be vetoed by Barack Obama if they weren't stopped first by
congressional Democrats, leading Republicans must have thought their scheme to
"repeal and replace" Obamacare was in the bag this year.
They had majorities in both
houses of Congress--and, crucially, a Republican in the White House who had
regularly promised to "repeal and replace" while on the campaign
trail. On his first day in office, Donald Trump showed his commitment to making
good on his promises with an
executive order instructing the new administration to do all it could
legally to dismantle the ACA.
Now, after half a year of
bluff, bluster and bumbling, congressional Republicans are on the verge of
failure.
Before this week, McConnell
had to give up on two previous attempts to bring health care legislation to a
vote. With only a narrow Republican majority, he was blocked by opposition from
two sides--the most reactionary GOP senators who didn't think McConnell's
version of Trumpcare went far enough, and a handful of "moderates"
fearful that the Republicans would be held responsible for the nightmare to
come if their legislation becomes law.
It was a rerun of the dilemmas
facing House Speaker Paul Ryan months earlier. Ryan overcame two false starts
to win
narrow approval in the House for the American Health Care Act by appeasing
the ultra-right in the final version of the bill.
McConnell tried the same
tactic by adding a
controversial amendment from right-winger Ted Cruz that would have further
loosened requirements that insurers cover essential health benefits and
services. But McConnell also tried to win over the "moderates" by,
among other things, retaining
two taxes on the wealthy implemented under the ACA, which Trump and the
Republicans want to eliminate.
Neither side was happy with
the concessions to the other, and Trumpcare seemed stalled again.
Adding to McConnell's
troubles, the
Senate parliamentarian ruled this week that key provisions of his proposal
fall outside limits of so-called "budget reconciliation," and so his
bill needed 60 votes, not just 51, to pass. Among the provisions affected by
this ruling are those nearest and dearest to the hearts of conservative Republicans,
such as defunding Planned Parenthood and prohibiting the use of government
subsidies to purchase health care plans that cover abortion.
Then came McConnell's latest
scheme--concocted under pressure from an irate twitterer-in-chief, who
continued abusing Republican senators throughout the week--to vote to proceed
to debate, though no one seemed really sure what they would debate and vote on.
But after that
"triumph" on Tuesday, nothing went right for Republicans. McConnell's
proposal for "repeal and replace," incorporating the amendments from
Cruz and other Republicans, went down by a wide margin of 43 to 57. On
Wednesday, a "repeal only" plan was defeated, by a smaller but
still-comfortable margin of 45-55.
Having found it impossible to
find a majority of senators to vote for the Republicans' more substantial
proposals, McConnell elected to punt--with the so-called "skinny
repeal" proposal that was never intended to be a final version that would
become law.
"Skinny repeal" was
a maneuver to get the process out of the public eye--and give Republicans the
chance to come up with yet another version in the conference committee. But
even that didn't work.
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ONE OF the confusing aspects
of the Republican health care fiasco is that some of the most furious
opposition to the various versions of Trumpcare came from right wingers who
think the bills didn't go far enough in dismantling the ACA.
That's hard to understand,
because for anyone not in the 1 Percent or close to it, everything the
Republicans took up was a nightmare in the making.
The centerpiece of all the
"repeal and replace" proposals was a drastic reduction in the federal
government's Medicaid health program for the poor.
The ACA attempted to expand
Medicaid eligibility to cover most people with income at or below 138 percent
of the federal poverty level. The Republican plans would roll back the Medicaid
expansion in all states, and impose a new per-person spending cap on the
portion of the program that remains. They would also, in common with the House
bill passed in May, permit states to impose work requirements on Medicaid
enrollees.
In addition, the GOP wants to
drastically reduce Obamacare's subsidies to individuals who must, under the ACA
individual mandate, purchase non-group insurance plans. The subsidies go to
people whose income falls within a range of between 100 and 400 percent of the
poverty line.
The combined effect of these
cuts, in all of the Republican proposals this year, was the elimination of more
than a trillion dollars in support for people on the lower end of the income
scale to help them access health care.
The legislation passed by the
House proposed cuts to Medicaid and subsidies totaling $1.11 trillion over 10
years--with about three-quarters of the cuts coming in Medicaid. Incredibly,
McConnell's first Senate proposal, which was supposed to be less heartless than
the House's, cut a total of $1.18 trillion from Medicaid and subsidies.
All of the GOP proposals were
estimated to add in excess of
20 million people to the ranks of the uninsured over the next decade--though
the "repeal only" bill floated by Trump tops them all at 32 million new
uninsured.
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WE CAN celebrate that
"repeal and replace" has collapsed. But it would be a grave mistake
to suppose that the GOP's assault is at an end.
For one thing, Trump has the
potential to wreak great havoc without any help at all from Congress. Rather
than simply "let" Obamacare fail, as he continually threatens on
Twitter, Trump can take steps to ensure that it does.
For example, as
the New York Times reported, Trump could unilaterally suspend payment of
cost-sharing reductions (CSRs)--subsidies established by the ACA that are paid
directly to insurance companies to help cover out-of-pocket costs for
lower-income people who buy policies on the "exchanges" established
by Obamacare.
The White House has announced
that it
will make the CSR payment for July, but the status of the subsidies is,
according to deputy press secretary Sarah Huckabee Sanders, "undetermined
beyond that."
The Times article points out
that this could lead more insurance companies to pull out of selling policies
under the ACA exchanges. But the truth is that the pullouts began some time
ago--a prime indication of the trouble Obamacare was already in, quite apart
from anything Trump might do to it.
In May, Reuters
reported that insurance giant Aetna had pulled out of the Obamacare exchanges
in Delaware and Nebraska, completing its withdrawal, begun
in 2016, from every exchange in which it had participated. Meanwhile,
Humana and UnitedHealth Group "have also pulled out of most of the
government-subsidized individual health insurance market," Reuters noted.
From the point of view of the
insurance companies, the ACA exchanges put them in the position of offering
policies to too many "high-risk" consumers--that is, those who are
likely to require substantial payouts due to chronic or serious health
conditions--compared to "low-risk" customers who need only minimal
care.
In the twisted world of
insurance companies, too high a percentage of high-risk policyholders--that is,
too many sick people--means an unacceptably high amount of money paid out, and
thus an unacceptable loss of profits.
The ACA's solution to this
problem for the health care industry was the "individual mandate,"
which requires most Americans to either purchase health insurance or pay a tax
penalty.
The individual mandate, and
the CSR payments that help to support it, generate billions of dollars a year
for the insurance industry. The CSRs alone are estimated
to total some $7 billion in 2017.
Nonetheless, insurance
providers such as Aetna and UnitedHealth had already decided--before Trump came
along to add extra uncertainty--that the system wasn't profitable enough. A
Consumer Affairs report from November 2016 describes, for instance, how
UnitedHealth made the decision to exit the ACA exchanges last year--despite record
profits in 2015 and projections indicating an "even better year" as
of mid-2016.
The consequences of insurer
pullouts can be seen in the limited, and sometimes nonexistent, enrollment
options projected for many consumers in 2018.
According
to the New York Times, residents of 45 counties, totaling 35,000 people,
may discover there are no insurance carriers at all to choose from on the ACA
exchanges--and a further 3 million people in 1,388 counties may have only one
carrier to choose from.
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WHILE THE Republican attempts
at "repeal and replace" were floundering, where did the Democrats
stand?
Now that the GOP has failed to
get a bill through the Senate on a strict party-line vote, they will either
have to leave it to the administration to dismantle as much of the ACA as
possible--or seek some form of compromise with at least some Democrats. That's
what John McCain was calling for explicitly with his vote to defeat the
"skinny repeal" proposal.
On July 18, Senate
Minority Leader Chuck Schumer set out the official Democratic position:
"Rather than repeating the same failed partisan process yet again,
Republicans should work with Democrats on a bill that lowers premiums, provides
long-term stability to the markets, and improves our healthcare system."
Though the remark was probably
intended as a mere rhetorical talking point, Schumer's choice of words is
actually very revealing.
The only way to ensure "long-term
market stability" under either Obamacare or Trumpcare is to create
conditions that are sufficiently profitable for the insurance companies that
they will remain in the marketplace--which brings us to the fatal flaw at the
heart of the ACA itself.
Obamacare is dependent on the
participation of private, for-profit insurance companies. Without them, the
whole system collapses. Therefore, keeping the insurance vultures happy must be
a top priority. That means making sure that the system remains profitable for
the insurers--which means in turn that the health care options available to
consumers will be determined not by what they need, but by what the insurers
want.
That's why, as of the end of
2016, there were still some
28.6 million people in the U.S. without health insurance. It's why 63
million people last year reported "not getting needed care because of
cost--including many who did have some form of health insurance.
It's why, under Obamacare
today, individuals and families who qualify for a
"hardship" or "affordability exemption"– meaning they
are unable to afford any of the plans normally available to them under the
ACA--receive no assistance beyond a waiver of the tax penalty under the
individual mandate, plus the opportunity to buy a laughably inadequate
"catastrophic health plan" which won't cover anything until they've
spent enormous sums out of their own pocket.
It is also telling that
Schumer spoke not of lowering overall health care costs, but of lowering premiums.
As
the San Jose Mercury News reported in 2016, there is a growing trend
towards low-premium, high-deductible plans, particularly in the realm of
employer-provided health care coverage.
These plans are doubly
beneficial to insurers: the low premium makes the policies attractive to
individuals or employers seeking "cheap" health care, while the high
deductible means the individual policyholder or employee ends up paying a
significantly higher portion of the overall cost of care.
So people are stuck with
insurance that is only really "affordable" if they don't actually use
it.
All this focus on "affordability"--reflected
in the name of the ACA, no less--necessarily implies a system where the
individual will always be expected to cover at least part of the cost of their
health care out of their own pocket.
That this assumption goes
unchallenged, even by the most supposedly "progressive" members of
the Democratic Party, reveals the extent to which both parties are committed to
the neoliberal creed of "personal responsibility"--where lavish
government handouts are reserved for Wall Street, big business and the
obscenely wealthy, while everyone else is expected to shoulder "their fair
share" of any economic burden.
In practice, our
"share" is anything but fair. As Helen Redmond wrote
in the International Socialist Review in 2014, for millions of people,
Obamacare isn't a matter of affordable care, but of "unaffordable
underinsurance."
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OF COURSE, the Republican
plans to replace the ACA are much worse in nearly every detail. It is no
accident that the most positive elements of the ACA--Medicaid expansion, a
robust list of "essential health benefits" to be covered by all
policies, guaranteed protection for patients with pre-existing
conditions--would be gutted or destroyed entirely if any of the versions of
Trumpcare ever becomes law.
This is no trivial matter. As
the Congressional Budget Office analyses of all the various Republican bills
made clear, the well-being of literally millions of people hangs in the balance.
But at a fundamental level,
the two parties agree on the government's role in the health care system: to
provide limited financial assistance to a limited number of people, and then
expect these individuals, along with everyone else, to pay for their own health
care coverage.
This vision is inhumane and
unacceptable. We must instead demand a health care system whose aim is to
provide comprehensive health care for all people--without exception.
All of the various problems of
the U.S. health care system--from insurers pulling out of the ACA exchanges, to
underinsurance and high out-of-pocket costs for policyholders, to millions of
people still having no coverage at all--could be solved at a single stroke with
a national single-payer, "everybody in, nobody out" health care plan.
These problems melt away when
health care is no longer something you must pay for, in whole or in part, but
something that is guaranteed by the state as a basic human right.
Neither Trumpcare nor
Obamacare will do. We must demand single-payer health care for all.
The only way to defeat Trump—
and to redeem what is worth saving in liberal democracy—is to detach ourselves
from liberal democracy’s corpse and establish a new Left.
Elements of the program for
this new Left are easy to imagine.
Trump promises the
cancellation of the big free trade agreements supported by Clinton, and the
left alternative to both should be a project of new and different international
agreements.
Such agreements would
establish public control of the banks, ecological standards, workers rights,
universal healthcare, protections of sexual and ethnic minorities, etc.
The big lesson of global
capitalism is that nation states alone cannot do the job—only a new political
international has a chance of bridling global capital.
Excerpt from:
“We Must Rise from the Ashes
of Liberal Democracy”
BY Slavoj Žižek
http://inthesetimes.com/article/19918/slavoj-zizek-from-the-ashes-of-liberal-democracy
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