Sunday, June 18, 2017


“‘I’ve said from Day 1, and I’ll say it again,’ said Senator Bob Corker, Republican of Tennessee. ‘The process is better if you do it in public, and that people get buy-in along the way and understand what’s going on. Obviously, that’s not the route that is being taken.’” New York Times, June 15th. What? Democracy works better with open debate and clear transparency in the legislative process? Especially on bills that are at the top of national debate? That impact “most of us”? Really? So if you are drafting that kind of legislation but are swearing the drafting legislators to secrecy, excluding any members of the party not in power, is that by definition undemocratic, un-American and unpatriotic?
But that is precisely what the GOP faction of the U.S. Senate is doing in “reconciling” a House bill – the American Health Care Act (AHCA) – that even Donald Trump has called “mean.” The legislation is critical to the entire Republican election-platform. Unless billions of dollars are cut from federal healthcare commitments, they cannot pass the tax reform legislation that will benefit the top 5% of earners at the expense of the rest of us. They promised better and more affordable healthcare by “repealing and replacing” the Affordable Care Act (Obamacare) plus that massive tax reform. Those two pledges appear to be mutually exclusive.
The “incent the job creators” theory of lowering taxes to create jobs – recently going down so violently in flames that even ultra-conservative Kansas Republicans wound up having to override a Tea Party Governor to reverse that clearly failed tax reform strategy (see my June 11th blog, Moderate Republicans: Extinct or Rising?, for the details) – is the cornerstone of GOP tax reform proposals. With strong pressure from super-conservatives to balance the budget, a powerful reduction in such tax revenues (trillions of dollars over the next decade), spending has to plunge.
But with an increase in defense spending an equally powerful plank in the GOP platform, not to mention a mega-billion-dollar wall that is unlikely to accomplish its desired border containment mission, what left is to downgrade, unwind or defund, federal regulatory agencies, foreign aid (not a particularly large segment of our federal budget), scientific research, even Trump’s promised infrastructure investment and, most of all, contract federal spending on social programs… pare it to the bone or phase it out. Federal support for education? An unneeded luxury that needs to be cut. School lunch programs? A waste. Consumer protection? Nope, cut that too. Environmental and financial regulation? You have got to be kidding. But most of all, look at the biggest absorber of federal money (other than deficit interest): Social Security, Medicare, Medicaid and… wait for it, wait for it… any form of national health care.
Leaks from that secretive GOP drafting session for the AHCA reconciliation, where our elected representatives are trying to put lipstick on a pig, are truly frightening. Look at the House proposal. The Congressional Budget Office noted that over the coming decade, as poverty continues to grow and as healthcare options are being taken off the table, the Medicaid budget would be slashed by $800 billion. The deficit would be cut by $330 billion. Even with these cuts, states would have to add $10 billion a year to fund parts of the cuts the AHCA that the House mandated.  23 million Americans would lose coverage. “Mean.”
So in order to cut services, shift costs back to individuals and states, Republicans have to figure out how make the bill look “less mean” but deliver enough savings to allow that tax cut that mostly benefits the rich to pass. To them, it’s an “either/or” choice, and tax reform is the priority. Word filtering out of Washington that if they can make the “premium” costs seem reasonable, even if the “co-pay” or “deductible” is staggeringly high, maybe folks won’t notice that they are paying for plans that they cannot afford to use for anything major. If you are under 40 with no serious health issues, wooo hooo! You win! If you are over 40 or have serious health issues, unless you have lots of spare cash to cover those ailments (and if you are, you probably have a chi chi blue-ribbon healthcare policy anyway), you are screwed. And if you are poor and in a red state, forgetabout it!
So give me some statistics, Peter. OK. One of the most interesting set of numbers to look at is an arena in an exceptionally common medical procedure. It is literally our healthcare “canary in a coal mine.” Maternal mortality, women dying in childbirth, is looked upon as a reasonable indicator of healthcare standards. Of the red states, Texas is far and away the richest. But it is also a very conservative state at every level. They opposed Obamacare, refused to expand Medicaid, and their GOP congressional delegation is intent on minimizing national healthcare “socialism.” A rich state that can afford much, much better, Texas has become the poster-child of letting those who cannot afford health insurance twist in the wind… and die. The statistics scream the obvious results.
“Maternal mortality rates have been edging up in much of the United States. A study published last year in the Medical Journal of Obstetrics & Gynecology found that the national rate rose 26 percent from 2000 to 2014. Systemic health problems across the country, notably unequal access to care and high rates of chronic illness, seemed to play a key role.
“But Texas is in a category all by itself. For the first half-decade of the new millennium, maternal deaths were steady, hovering at around 18 deaths per 100,000 births -- not a particularly dramatic number. However, from 2011 to 2014 the number doubled. During those more recent years, more than 600 Texas women died from complications around childbirth. Those figures, the study concluded, didn’t make sense “in the absence of war, natural disaster or severe economic upheaval.
“If Texas were a country, it would have the highest maternal mortality rate in the developed world and would be on a par with Mexico or Turkey. ‘We’re trying to figure out how to get our rate down to a First World country,’ says Tony Dunn, chair of the Texas chapter of the American Congress of Obstetricians and Gynecologists. The question is not just why Texas has this problem, but also why it’s been getting so much worse and why it’s more severe there than in other states. There are no clear answers, but there are clues…
“Health-care experts know the factors that lead to maternal health: good access to care, adequate funding of services and the general health of the larger population. Texas ranks near the bottom on nearly every one of these metrics. It has the highest rate of uninsured residents of any state. Seventeen percent of Texas residents go without health insurance, a full 4 percentage points above the second highest state, Alaska. ‘Women in Texas have not historically had access to health care across their lifespan, so when they’re pregnant and have care, it’s really hard to treat those things in such a short amount of time,’ [according to Amy Raines-Milenkov, a member of the Texas task force charged with investigating maternal mortality].
“Every state offers some Medicaid benefits for pregnant women, even if they aren’t on Medicaid otherwise. However, Texas’ program is relatively paltry -- benefits end two months after giving birth. The state also has the second-highest number of undocumented immigrants after California, and those women are not eligible for benefits.
“Medicaid expansion might have helped ease this problem. Expanding Medicaid under the Affordable Care Act caused many states to see their uninsured numbers drop -- in some instances dramatically. But Texas was one of 19 states that chose not to participate in the expansion.”, May 2017. Those numbers, if widely known, would make the current GOP efforts to repeal and/or sabotage Obamacare, replacing it with a Texas-friendly substitute, an unequivocal concession to the rich and a slam to those struggling to survive in an increasingly-expensive world. So they conduct their drafting session in private, with only GOP insiders knowing what they are proposing. And as GOP Senator Bob Corker’s quote above suggests, they are clearly uncomfortable with what they are doing.
“[Senate secrecy in the AHCA reconciliation] has created an air of distrust and concern — on and off Capitol Hill, with Democrats but also with Republicans…
“The secrecy surrounding the Senate measure to repeal and replace the Affordable Care Act is remarkable — at least for a health care measure this consequential… Now Democrats say they would love to read the Republicans’ repeal bill, but cannot do so because Republicans have not exposed their handiwork to public inspection.
“‘They’re ashamed of the bill,’ the Senate minority leader, Chuck Schumer of New York, said. ‘If they liked the bill, they’d have brass bands marching down the middle of small-town America saying what a great bill it is. But they know it isn’t.’
“The Senate’s decisions could have huge implications: Health care represents about one-sixth of the American economy, and about 20 million people have gained insurance under the 2010 health law, President Barack Obama’s signature legislative achievement… In theory, the bill-writing process is open to any of the 52 Republican senators, but few seem to have a clear, coherent picture of what will be in the legislation.” NY Times.
That lack of coherent understanding stems from the fact that the legislators are relying on themselves and hearings they held a very long time ago without any current healthcare experts (economic/insurance versus the few medical doctors in the Senate) providing input. They are also trying to craft a response that allows a simple majority vote under Senate Rule 14 (which deals with how far that body can go, without debate or the risk of filibuster/cloture vote, in “reconciling” a bill sent to them after passing the House). The House has a similar, less used reconciliation process when bills emanate from the Senate, but that is not what concerns the AHCA.
“Reconciliation is a legislative process of the United States Senate intended to allow passage of a budget bill not subject to filibuster in the Senate. Reconciliation rules prohibit debate to exceed twenty hours under Senate rules
“The process was created from the Congressional Budget Act of 1974 and first used in 1980. The reconciliation rule allows tax, spending, and debt limit adjustments. However, larger policy change are limited due to the Byrd Rule, named after Democratic Senator Robert Byrd, after an amendment added in 1990. The Byrd Rule prevents using reconciliation bills that include language ‘extraneous’ to the budget.” Wikipedia.  
So the Senate cannot introduce materially new elements to a House bill and sidestep a full Senate voting process. They are checking with the Senate Parliamentarian to determine whether the changes they are making to the House AHCA bill will allow them to go to a direct-majority vote without a risk of filibuster (true “reconciliation”). Otherwise, the Democrats will be able to block the process. They are hoping that the distractions in Washington, the Russia-connection issues, the obstruction of justice investigation and terrorist attacks, will allow them to “sneak a vote.”
I’m Peter Dekom, and if you don’t like this secret process, scream to your elected representatives in Congress, Senators and Representative… to hold them accountable.

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