Donald J. Trump, the master brander, has never found quite the right selling point for his party’s health care plan.
He has promised “great healthcare,” “truly great healthcare,” “a great plan” and health care that “will soon be great.” But for a politician who has shown remarkable skill distilling his arguments into compact slogans — “fake news,” “witch hunt,” “Crooked Hillary” — those health care pitches have fallen far short of the kind of sharp, memorable refrain that can influence how millions of Americans interpret news in Washington... Mr. Trump is much better at branding enemies than policies. And he expends far more effort mocking targetsthan promoting items on his agenda... The word choice is memorable. But it’s also the repetition that’s important. In its simplicity and consistency, that message is textbook marketing.. Marketing research also suggests that the more we’re exposed to a belief or a brand, the more likely we are to believe that others share or use it. And so by repeating the slogan, Mr. Trump also feeds the notion that Mrs. Clinton is widely believed to be crooked... Psychologists have another term for what Mr. Trump does here that is so effective. He “essentializes” Mrs. Clinton and his other opponents, like Lyin’ Ted Cruz... This is the important difference between using a descriptive verb (“Ted Cruz tells lies”) and a noun label (“Lyin’ Ted”). Such minor manipulations of language, psychological research shows, can convey much more deep-seated, stable and central characteristics about a subject. And these labels preclude other identities... The only thing you need to know about Marco Rubio, according to Mr. Trump’s branding efforts, is that he lacks stature. And that’s a deeply embedded quality that the man can never change:.. But the affirmative case for the Republican alternative? None of his language has stuck. When Mr. Trump has tried to brand his party’s health care reform efforts in a positive light, his messages have largely taken the form of unmemorable promises about “better” or “great” health care in the future:.. If any word kept coming up — and this one’s not from his Twitter feed — it was his reference to the House bill as “mean.”.. debates over whether the ban should be called a ban... Mr. Trump for the most part hasn’t done that. He has used the tactic to promote himself: He is, above all, “a winner.” The endless repetition and emotional simplicity seemed to work during the campaign as he promoted the WALL (not a fence!). But now that he’s president, what if he cheered the Republican health plan as doggedly as he scorned “Crooked Hillary”? What if he devoted as much effort to defining the stakes of tax reform as he has spent branding his antagonists in the news media?
.. One possibility is that these subjects just don’t interest him as much. Or perhaps it’s much harder to condense the case for complex policies — codified in hundreds of pages of legislation and legalese, devised through countless compromises and trade-offs — down to the size of a hashtag. Either way, one of Mr. Trump’s most remarkable skills hasn’t proved an asset on Capitol Hill.
The announcement by the senators, Mike Lee of Utah and Jerry Moran of Kansas, left their leaders at least two votes short of the number needed to begin debate on their bill to dismantle the health law. Two other Republican senators, Rand Paul of Kentucky and Susan Collins of Maine, had already said they would not support a procedural step to begin debate.
.. In announcing his opposition to the bill, Mr. Moran said it “fails to repeal the Affordable Care Act or address health care’s rising costs.”
.. In his own statement, Mr. Lee said of the bill, “In addition to not repealing all of the Obamacare taxes, it doesn’t go far enough in lowering premiums for middle-class families; nor does it create enough free space from the most costly Obamacare regulations.”
.. But with conservative and moderate Republicans so far apart in the Senate, the gulf proved impossible to bridge. Conservatives wanted the Affordable Care Act eradicated, but moderates worried intensely about the effects that would have on their most vulnerable citizens.
.. “This second failure of Trumpcare is proof positive that the core of this bill is unworkable,” Mr. Schumer said. “Rather than repeating the same failed, partisan process yet again, Republicans should start from scratch and work with Democrats on a bill that lowers premiums, provides long-term stability to the markets and improves our health care system.”
.. the health insurance lobby, which had been largely silent during the fight, came off the sidelines to blast as “unworkable” a key provision allowing the sale of low-cost, stripped-down health plans, saying it would send premiums soaring and undermine protections for people with pre-existing medical conditions.
.. Mr. Lee, one of the most conservative members of the Senate, was part of a group of four conservative senators who came out against the initial version of Mr. McConnell’s bill after it was unveiled last month. He then championed the proposal to allow insurers to offer cheap, bare-bones plans, which was pushed by another of those opponents, Senator Ted Cruz of Texas.
A vocal conservative opponent of the measure, Sen. Rand Paul, predicted the delay would strengthen critics’ position by giving them more time to mobilize against the bill.
“The longer the bill is out there, the more conservative Republicans are going to discover it is not repeal,” Paul (R-Ky.) said Sunday in an interview with CBS’s “Face the Nation.”
Paul said he spoke with Trump on Friday and suggested the president support repealing the Affordable Care Act and deciding the details of a replacement plan later if the latest version of the bill does not pass.
.. Trump administration officials failed to gain support from influential Republicans such as Nevada Gov. Brian Sandoval (R). Opposition from Sandoval and others will make it easier for undecided Republican senators from those states to vote “no” on the bill, potentially further endangering its prospects.
.. (63 percent) believes it is more important for the government to provide health coverage to low-income people compared with cutting taxes (27 percent). Among Republicans, 48 percent favored cutting taxes, compared with 39 percent who favored providing health coverage for low-income people.
.. “President Trump and I believe the Senate health-care bill strengthens and secures Medicaid for the neediest in our society,” Pence said
.. Collins strongly disagreed in an interview Sunday with CNN.
“You can’t take more than $700 billion out of the Medicaid program and not think that it’s going to have some kind of effect,” she said during an appearance on “State of the Union.”
.. “This bill imposes fundamental, sweeping changes in the Medicaid program, and those include very deep cuts that would affect some of the most vulnerable people in our society, including disabled children and poor seniors. It would affect our rural hospitals and our nursing homes, and they would have a very hard time even staying in existence.”
.. Pence’s speech was criticized by Democrats, health-care advocates and even some Republicans for mischaracterizing the possible ramifications of the GOP bill.
.. During the same speech, the vice president went after Ohio Gov. John Kasich (R), a critic of the legislation, by suggesting his state’s expansion of Medicaid left nearly 60,000 residents with disabilities “stuck on waiting lists, leaving them without the care they need for months or even years.”
The claim alienated many at the meeting, partly because waiting lists for Medicaid’s home- and community-based services were not affected by the program’s expansion under the ACA, and partly because many interpreted Pence’s remark as an overly aggressive shot at Kasich. The Ohio governor’s stance against the bill could shape the position of Sen. Rob Portman (R-Ohio), a pivotal vote for Republicans who is undecided on the current version. Some fear Pence missed an opportunity to woo Portman with his remark against Kasich.
.. Collins estimated Sunday that there are eight to 10 Republican senators with “serious concerns”
.. Health and Human Services Secretary Tom Price and Seema Verma, administrator of the Centers for Medicare and Medicaid Services, worked to undermine that report and a forthcoming analysis by the Congressional Budget Office showing the legislation’s cost and insurance impact.
.. The Avalere study projected marked reductions in federal Medicaid funding to all 50 states, ranging from 27 percent to 39 percent by 2036.
When it comes to health care, there are lies, damned lies, and CBO-bashing.
.. But the really big push over the next couple of days will be the attempt to trash CBO estimates that are almost sure to show massive losses, even if the CBO is somehow prevented from considering the Cruz amendment.
.. everyone, and I mean everyone, who knows something about insurance markets is declaring the same thing: that this proposed bill would be a disaster. We’ve got the insurance industry declaring it “simply unworkable”; the American Academy of Actuaries saying effectively the same thing; AARP up in arms; the Urban Institute forecasting disaster; and more.
.. Yes, it overestimated the number of people who would sign up for the exchanges. But this was largely because it overestimated the number of employers who would drop coverage and send their workers to the exchanges. Overall, its estimates of coverage gains and premiums weren’t that far off,
.. Trumpcare – or maybe we should call it Cruzcare – is a leap into the known. Before the ACA, most states allowed insurers to discriminate based on medical history. Many also restricted access to Medicaid as much as they could. So we have a very good idea what health care in America would look like if the BCRA passes: it would look like health care in unregulated, low-aid states pre-ACA.
Or to not put too fine a point on it, it would look like health care in Texas circa 2010, with 26 percent of the nonelderly population uninsured.
.. It would establish a system very much like that which existed in those parts of America in which vast numbers of people lacked coverage in the past; why would this time be different?
the bill would allow people to use tax-favored health savings accounts to pay insurance premiums. This effectively creates a big new tax shelter that mostly helps people with high incomes
.. So this is still a bill that takes from the poor to give to the rich; it just does so with extra stealth.
.. So how does he address the two big problems with the original bill —
- savage cuts to Medicaid and
- soaring premiums for older, less affluent workers?
.. The most important change in the bill, however, is the way it would effectively gut protection for people with pre-existing medical conditions.
.. the new Senate bill gives in to demands by Ted Cruz that insurers be allowed to offer skimpy plans that cover very little, with very high deductibles that would make them useless to most people.
.. The main answer, I’d argue, is that what would happen if this bill passes — a big decline in the number of Americans with health insurance, a sharp reduction in the quality of coverage for those who keep it — is what Republicans have wanted all along.
.. the Republican elite considered and still considers people on Medicaid, in particular, “takers” who are effectively stealing from the deserving rich.
And the conservative view has always been that Americans have health insurance that is too good, that they should pay more in deductibles and co-pays, giving them “skin in the game,” and thus an incentive to control costs.
.. So what we’re seeing here is supposed to be the last act in a long con, the moment when the fraudsters cash in, and their victims discover how completely they’ve been fooled. The only question is whether they’ll really get away with it. We’ll find out very soon.
Democrats are preparing to challenge these provisions, among others:
Planned Parenthood: The Senate Republican bill would cut off federal Medicaid funds for Planned Parenthood for one year.
Age ratios: The Senate bill would let insurers charge older consumers five times as much as young adults. Under the Affordable Care Act, they can charge no more than three times as much. Democrats say the purpose of the change is purely regulatory, not budgetary
Waiting period: People who went without insurance for approximately two months in the prior year would be required to wait six months before they could start coverage under the Senate bill. Democrats say the purpose is not to save money, but to regulate insurance and to encourage people to obtain coverage without imposing an “individual mandate.”.. Democrats are also expected to challenge a provision of Mr. McConnell’s bill that would allow states to impose work requirements on some Medicaid beneficiaries.. And they are prepared to challenge a proposal by Senator Ted Cruz, Republican of Texas, that would allow insurers to sell stripped-down insurance, free of most federal regulations, if they also offered at least one plan that complied with insurance standards like those in the Affordable Care Act. Health plans could, for example, omit coverage of maternity care or mental health care.
Trump has repeatedly praised Canada’s health-care system, which has a very similar structure to Medicaid, as offering a model for the United States to emulate. However, the reforms proposed in both the House and the Senate bills would in fact bring Medicaid even closer to the structure of Canada’s health-care system — only with a far more generous level of funding.
.. Canada’s federal funding system was established in 1957, with the national government providing one dollar for every dollar that provinces spent on hospital and physician services. By the 1970s this arrangement was widely recognized to be causing costs to soar, and the Liberal prime minister Pierre Trudeau reformed this “Canada Health Transfer” so that provinces would receive a fixed annual allocation from the national government.
.. The U.S. Medicaid matching payment to states ($344 billion, or $1,071 per American, in 2015) already well exceeds the Canadian block grant to provinces (US$26 billion, or US$716 per Canadian) — even though the Canada Health Transfer is supposed to cover Canadians of all ages and income levels, whereas Medicaid is dedicated to 21 percent of the U.S. population with low incomes.
.. U.S. federal taxpayers spend an additional $646 billion on Medicare, and $122 billion on other health entitlements such as CHIP or VA — yielding total federal health-care entitlement spending of $3,461 per capita.
.. Canada is not getting more value for money; it is just getting fewer services. Canada’s federal payment doesn’t cover prescription drugs; only hospital and physician services are paid for. Canada also saves money by rationing operating-room time and the ability of physicians to order costly services.
.. Nor does Canada pay significantly less for its physicians than the United States; it just limits access to the expensive ones. In 2010, family physicians earned incomes (net of practice expenses) averaging $159,000 in the United States and US$156,000 in Ontario, while cardiologists averaged $325,000 in the United States and US$283,000 in Ontario. According to the World Bank, the United States has 2.45 and Canada 2.07 physicians per 1,000 inhabitants, while the United States has 0.55 specialist surgeons per 1,000 and Canada 0.35.
.. Waiting lists save lots of money because some patients get better by themselves, others give up seeking care, and a substantial number die before receiving treatment.
.. the allocation of federal payments by open-ended matching has caused funds to be distributed according to how much states can themselves afford to put in. As a result, the states that need help the least received the most assistance. In 2015, Connecticut collected $12,240 in federal Medicaid funds per resident under the poverty line, whereas Alabama received only $4,070.
To keep funds from being captured by the richest states (which generally use them to expand eligibility to wealthier individuals who mostly already had private coverage), it therefore makes sense to cap the increase in funding that each state is able to claim from the federal government every year.
.. The Canada Health Transfer currently increases the funds received by each province at a standard rate of 3.0 percent every year. By comparison, the House GOP’s proposed reform would limit the annual increase in federal payments claimed by each state to a statistic that has increased around 7.0 percent for spending on the aged and disabled and 4.9 percent for that on able-bodied adults and children