Path to repealing Obamacare unclear

Repeal ObamacareWhen the next Congress takes office in January, with a new Republican majority in the U.S. Senate complementing an expanded Republican majority in the House, the Affordable Care Act figures to show up near the top of the agenda.

They’ve come to like at least a few of its provisions, such as the one allowing parents to provide coverage under their plans to their children until the kids turn 26, and the restrictions on denying coverage due to pre-existing medical conditions. Repealing the ACA in toto and then reinstating those provisions with no lapse in coverage could be tricky.

Then there’s “Oh yeah? You got a better idea?” — a concept that goes a long way to explaining why the existing Republican majority in the House has not brought up an “Obamacare” alternative for a floor vote.

In early June, Republican U.S. Rep. Steve Scalise, of Jefferson, was pushing for a floor vote on an “Obamacare” alternative. Scalise was then chairman of the Republican Study Committee, an extra-conservative enclave within the House Republican majority, and he favored an RSC alternative to “Obamacare” that he had unveiled with some fanfare in 2013.

But the House Republican leadership, and many other Republicans, demurred. They figured the political winds were blowing in the Republicans’ favor, in part because of widespread dissatisfaction with “Obamacare,” so why mess with a good thing before the November elections? The leadership did promise Scalise that it would bring an alternative to the floor by the end of this year, an RSC aide said, even if that meant during the lame-duck session after the elections.

Scalise is no longer RSC chairman: He is now part of the Republican leadership himself, as majority whip, a post he assumed in mid-June. The elections are over, and the winds did blow the Republican way. But if the Republicans are bringing an “Obamacare” alternative to the House floor before the end of the year, they are being awfully quiet about it.

Meanwhile, Louisiana Republican U.S. Sen. David Vitter is sharpening his focus on a particular slice of the “Obamacare” pie: the so-called exemption for members of Congress and their staffs.

The issue has its roots in 2010, when the law was working its way through Congress. Republican U.S. Sen. Chuck Grassley, of Iowa, won approval of an amendment that required the federal government to stop offering members of Congress and their staffs the government-wide Federal Employee Health Benefits Plan — a typical workplace plan, with the employer paying about 75 percent of health coverage premiums and the employee paying the rest — but instead to “make available” only plans marketed through ACA insurance exchanges.

That left the members and their staffs in a sort of limbo: Unlike every other employer in the country, theirs could not offer them a standard workplace health plan and pick up most of the tab. The Obama administration then stepped in to promulgate a rule that said the government would continue to pay its share of the employees’ coverage provided they purchased it through the District of Columbia’s small-business exchange under the health law — something no other employer can do for exchange-provided coverage.

But there’s another wrinkle: The Grassley amendment allows members of Congress to designate some or all of their staffers exempt (that word again) from the amendment’s scope, pretty much at the members’ discretion.

Vitter wants to end the special treatment for Congress under “Obamacare” — by treating members and staffers in a different way that seems just as special but also somewhat punitive. Under his proposal, everyone from House Speaker John Boehner, of Ohio, to the lowliest Senate office receptionist would be required to buy health insurance through an ACA exchange — but could receive neither the employer contribution available to millions of workers across America nor the “Obamacare” subsidies available to millions more on the exchanges.

The Republican-controlled House recently rejected a similar proposal, and several Republican Senators dislike the idea, so Vitter has his work cut out for him.

Gregory Roberts is chief of The Advocate Washington bureau. Follow him on Twitter, @GregRobertsDC. For more coverage of government and politics, follow The Advocate Politics Blog at http://blogs.theadvocate.com/politicsblog/.

Half of the senators who voted for Obamacare will be gone next year

We’ll give credit to the conservative Washington Examiner for being first out of the gates with an idea that will make Republican political types salivate: Half of the senators who voted for Obamacare won’t be in the Senate in 2015. Bloomberg included that in its by-the-numbers recap of the election. And it’s true. Sixty senators (58 Democrats, two independents) voted for Obamacare in 2009, and six years later, only 30 will be in the Senate. The subtext is obvious: Obamacare is political poison.

So we must note the corollary. Of the 39 Republicans who voted against the Affordable Care Act (one didn’t vote), 24 — 60 percent — will still be in office come January. Which shifts the frame a bit.

There’s no question that a number of Democrats were defeated because constituents rejected their politics. How closely those losses are linked to Obamacare is hard to evaluate. Did Sen. Mary Landrieu (D-La.) lose this weekend  because she voted for Obamacare five years ago, or did she lose because the politics in the South have shifted? Odds favor the latter. But more importantly, only eight of the 29 Democrats who backed Obamacare were actually defeated — and five of them were defeated this year, well after their initial vote for the ACA. The rest of the Democrats retired or left the Senate for other reasons.

Here’s the breakdown, by party. For those that left office, their replacements are color-coded by party.

There is no question that Democrats have had a bad run since 2009. Only one of the Republicans who left office was replace by a Democrat (and one was replaced by an independent), but 16 of the Democrats were replaced by Republicans. That, broadly, may be because of Obamacare; it’s certainly, in large part, because of Obama.

This is another case in which the top line number is much more murky than it at first appears. Obamacare is not the political winner that Democrats hoped and expected it to be. But it’s not necessarily the political loser that the Examiner headline might lead you to believe either.

Philip Bump writes about politics for The Fix. He is based in New York City. This post first appeared in The Washington Post.

Still cooking the ObamaCare books

The ObamaCare lies keep coming. In two highly publicized announcements last week, top Obama health officials claimed the Affordable Care Act is slowing health care spending and improving hospital safety.

The media parroted these boasts, but the evidence shows they’re bogus.

Even as administration figures — from President Obama down — distance themselves from Jonathan Gruber, the ObamaCare adviser caught calling the public stupid, they’re still relying on his playbook: They assume we’re not going to check their facts.

On Dec. 3, federal actuaries released data showing that health spending inched up only 3.6 percent in 2013.

Marilyn Tavenner, the head of Medicare and Medicaid, boasted that it’s “evidence that our efforts to reform the health-care-delivery system are working.” Sorry, not true.

That 3.6 percent figure is an improvement only by a hair.

The real slowing of health care spending started way back in 2009, in the wake of the Great Recession, long before ObamaCare even passed. Health spending slowed to a comfortable 3.8 percent rise that year, and stayed at that slow pace in 2010.

Not that the president acknowledged that health spending was growing at the slowest rate in a half-century.

To pass his health bill, he needed a crisis. So he and then-Secretary of Health and Human Services Kathleen Sebelius repeatedly lied, warning that costs were“skyrocketing,” spending was “spiraling” out of control and health needs would gobble up ever more GDP unless Congress quickly passed the Affordable Care Act.

Fast-forward to today. There’s nothing remarkable about the 3.6 percent rate in 2013. But there is bad news ahead, thanks to the Affordable Care Act.

Federal actuaries predict that health spending increases will nearly double soon, averaging 6 percent a year through 2023, pushing total health spending to a staggering 19.3 percent of GDP, up from 16.6 percent pre-ObamaCare.

So much for ObamaCare controlling costs.

What of the boast that the president’s health law is making it safer to go to the hospital? Don’t bet on that, either.

On Dec. 2, Health and Human Services Secretary Sylvia Burwell announced “demonstrable progress” in making hospital care safer.

Her report claims that some 50,000 fewer patients died from bed sores, infections, medication errors, falls and other mishaps from 2010 to 2013, largely due to new payment incentives and a patient safety program in ObamaCare.

That happy claim was repeated verbatim by many media outlets.

Not so fast, say patient safety experts who actually read the report.

Dr. Peter Pronovost, senior vice president for patient safety and quality at Johns Hopkins Medicine, and Dr. Ashish Jha of the Harvard School of Public Health had already taken to the pages of the New England Journal of Medicine to caution about the patient safety program’s cherry-picking methodology, lack of data transparency and unsubstantiated claims.

“It’s nearly impossible to tell,” they said, whether the program’s changes “led to better care.”

The administration bragged about reducing infections, but didn’t count the type of infection that kills the most patients — Clostridium difficile or C. diff.

That’s like a kid’s report card that leaves out reading and math. It doesn’t tell the whole story.

Truth is, C. diff is raging through hospitals. Centers for Disease Control and Prevention head Thomas Frieden calls it one of the “nightmare bacteria.”

It kills 14,000 patients a year, and increases your risk of dying while in the hospital by 75 percent.

The Leapfrog Group, a trusted patient safety advocacy outfit, released a new assessment of US hospitals on Oct. 30 that gave 41 percent of hospitals C, D or F grades because patients there were harmed by medical mistakes, falls and other injuries and infections.

According to Leapfrog, progress on patient safety is stagnant — and by some measures hospitals are doing worse. That’s the opposite of what the administration claims.

Finagling data is nothing new for the Obama team. Just weeks ago, it was caught red-handed inflating ObamaCare enrollment numbers by counting dental-only plans as health insurance.

Truth is, four years after its passage, the ACA has managed to cover only one out of four previously uninsured people, spending $57 billion to do it.

And it’s forced millions to give up plans they liked and pushed employers to cut hours and jobs — as well as inciting voters to retire dozens of Democratic members of Congress.

Instead of lying about ObamaCare, some top Democrats are taking another tack, distancing themselves from this increasingly toxic issue. Shrewd politicians like Sens. Charles Schumer (D-NY) and Tom Harkin (D-Iowa) can spot a loser.

Betsy McCaughey is chair of the Committee to Reduce Infection Deaths and a senior fellow at the London Center for Policy Research.

ObamaCare’s Threat to Private Practice

The payment system is forcing doctors to sell out to hospitals. The trend, and the law, will be unstoppable without reform.


Here’s a dirty little secret about recent attempts to fix ObamaCare. The “reforms,” approved by Senate and House leaders this summer and set to advance in the next Congress, adopt many of the Medicare payment reforms already in the Affordable Care Act. Both favor the consolidation of previously independent doctors into salaried roles inside larger institutions, usually tied to a central hospital, in effect ending independent medical practices.

Republicans must embrace a different vision to this forced reorganization of how medicine is practiced in America if they want to offer an alternative to ObamaCare. The law’s defenders view this consolidation as a necessary step to enable payment provisions that shift the financial risk of delivering medical care onto providers and away from government programs like Medicare. The law’s architects believe that doctors, to better bear financial risk, need to be part of larger, and presumably better-capitalized institutions. Indeed, the law has already gone a long way in achieving that outcome.

A recent Physicians Foundation survey of some 20,000 U.S. doctors found that 35% described themselves as independent, down from 49% in 2012 and 62% in 2008. Once independent doctors become the exception rather than the rule, the continued advance of the ObamaCare agenda will become virtually unstoppable.

Local competition between providers, who vie to contract with health plans, is largely eliminated by these consolidated health systems. Since all health care is local, the lack of competition will soon make it much harder to implement a market-based alternative to ObamaCare. The resulting medical monopolies will make more regulation the most obvious solution to the inevitable cost and quality problems.

A true legislative alternative to ObamaCare would support physician ownership of independent medical practices, and preserve local competition between doctors and choice for patients.

First, Congress should remove the pervasive biases in ObamaCare that favor hospital ownership of medical practices. Payment reforms that create incentives for the coordinated delivery of medical care (like Accountable Care Organizations and payment “bundles”) all turn on arrangements where a single institution owns the doctors. They’re biased against less centralized engagements where independent doctors enter into contractual relationships among themselves.

These ObamaCare payment reforms are fashioned after 1990s-style health maintenance organizations, or HMOs, in which entities like hospitals would get a lump sum of money from Medicare (or now, ObamaCare) for taking on the risk of caring for a large pool of patients. But right now all of these payment schemes are tilted far in favor of having hospitals pool that risk, and not looser networks of doctors.

For one thing, providers who want to participate in the “reformed” physician payment plan must control their own IT infrastructure to comply, as opposed to collaborating freely across space rented in the cloud. This practical need can require IT infrastructure that costs millions of dollars. It makes participation absurdly expensive for anyone but a hospital that already has its own server hub.

Also, waivers of certain anti-kickback provisions (that prevent doctors from forming needed business partnerships) only apply when providers qualify as an Accountable Care Organization. Not surprisingly, ACO qualification is largely dependent on requirements that create the same need for physical infrastructure and bureaucratic overhead that is hard to replicate outside the hospital setting.

To implement real reform, Congress must give independent, private-practice doctors an equal footing. One legislative proposal would let a new class of “independent risk managers” act as third parties to help individual doctors analyze and share the risk of caring for these patient pools. This would make it possible for independent medical offices to band together and bid against hospitals for a pool of patients. Private companies specializing in analyzing and pricing medical risk could serve as brokers and help the doctors know what they’re getting into. But ObamaCare deliberately crowds out this sort of market innovation in favor of hospitals and their existing networks.

Individual, provider-owned medical practices also deserve equal footing when it comes to reimbursement. Right now, Medicare is paying much more for many procedures when performed in a hospital outpatient clinic rather than an independently owned medical office. Things as common as heart scans ($749 versus $503), colonoscopies ($876 versus $402) and even a 15-minute doctor visit ($124 versus $70) all pay more when done by a hospital-based doctor than a privately owned medical office. Obama officials know that hospitals are buying doctor practices to take advantage of this difference. But they favor hospital ownership of doctors and see it as a small cost to pay to drive that migration.

When I talk to physician colleagues, Republican or Democrat, a frequent refrain is that their professional strain would be the same regardless of what happens to ObamaCare. They are wrong. ObamaCare has accelerated many of the detrimental trends doctors see in their profession, and introduced new ones.

Reformers in Washington need to do a better job of explaining how market-based alternatives to ObamaCare are a better outcome for the structure and delivery of health care. And how they intend to preserve the entrepreneurship, autonomy and physician ownership that have long been the hallmark of American medicine.

Dr. Scott Gottlieb, a physician and resident fellow at the American Enterprise Institute, is a member of the Health IT Policy Committee that advises the Department of Health and Human Services. He also invests in and advises health-care companies.

Did Obamacare destroy the Democratic Party? Another View

Michael Hiltzik of the LA Times asks if Obamacare destroyed the Democratic Party.

Was heathcare reform a fatal political blunder by the Democratic Party? That thesis of Sen. Charles Schumer of New York, the third-ranking Democrat in the Senate, received a respectful airing this week from the veteran political journalist and New York Times columnist Thomas B. Edsall.

Edsall observes that hostility to Obamacare from white voters is a menacing counterweight to the party’s demographic advantages in the next presidential election. “Whatever you think of Senator Schumer,” he writes, “you begin to understand why he spoke out as forcefully as he did.”

Edsall cites my own critical analysis of Schumer’s remarks, delivered to an audience of Washington journalists on the Tuesday before Thanksgiving, as an example of the pushback he’s gotten from supporters of the Affordable Care Act. Schumer’s position–that the Democrats should have delayed healthcare reform at the start of Obama’s first term and focused instead on policies to help the middle class–goes to the heart of what it means to govern. It’s proper to give it a closer look.

It’s even more important to examine the misconceptions about Obamacare that lie at the heart of Schumer’s analysis. The fundamental flaw in that analysis is a misunderstanding of Obamacare, as some of Edsall’s own data reveal. The lesson, as I’ve written before, is that the Democrats’ blunder was not in passing the bill, but in running away from it once it became law and abandoning it to be defined–misdefined–by their Republican opponents.

As Edsall observes, “Obamacare” has been broadly unpopular. He cites a November 2013 poll by National Journal in which a large plurality (and a majority of whites) stated that the law would make things worse for themselves. Most thought it would make things worse for the middle class.

But the poll underscored a well-known problem with the law: most people didn’t, and still don’t, understand what’s in it. That’s the Democrats’ own fault. The National Journal poll was designed to reinforce respondents’ negative perceptions of “Obamacare,” then asked them what they thought about it; why would anyone be surprised that the results tilted negative? The poll questions mentioned the glitchy launch of healthcare.gov and the brouhaha over cancellations of existing policies. These were big deals at the time; soon afterward, however, the first problem was resolved and the second concern shown to be grossly inflated.

But the poll did nothing to probe whether respondents actually understood what was in Obamacare for them. This is a serious flaw, because other surveys, notably by the Kaiser Family Foundation, have shown repeatedly that voters strongly favor almost all of the actual features of Obamacare, including the end of insurance denials and jacked-up premiums for pre-existing medical conditions, lower drug prices for Medicare enrollees, the right to keep children on employer health plans to age 26, tax credits for small businesses to buy insurance, and the expansion of Medicaid.

Not a single one of these provisions was mentioned by National Journal’s polltakers. More to the point, they were almost never cited by Democrats running in the 2010 or 2014 Congressional elections. Nor was the fact that the ACA had brought low-cost health insurance to an estimated 10 million Americans who were previously uncovered.

It’s worth repeating that while the ACA is a boon to low-income Americans, especially in states wise enough to take advantage of its federally funded Medicaid expansion, it incorporates a strong middle-class benefit. Premium subsidies in the individual market extend to families earning up to 400% of the federal poverty level. For a couple with two children, that comes to $95,400; doesn’t Schumer consider that a middle-class income?

So the Democrats’ problem wasn’t Obamacare so much as faulty messaging. Think of how things might have been different if every time a Republican or Koch-backed political organ trotted out a purported Obamacare “victim” (most of which cases were bogus), a Democratic organization produced an Obamacare winner from among those 10 million new insurance holders. (They weren’t hard to find.)

As the Washington Monthly’s Ed Kilgore writes, the Democrats utterly failed to explain Obamacare “as an economic initiative” defending the middle class from a poorly regulated health insurance industry. Kilgore and others have pointed out the other big hole in Schumer’s rant about the lack of Democratic ideas to help the middle class: It was light on practical specifics.

Schumer mentioned a few: supporting the prosecution of bankers for their role in the financial crisis, raising taxes on CEOs, “changing labor laws so workers could demand more pay.”

These are all sound. On the prosecution of bankers, if Schumer’s spoken out on this topic before, it certainly hasn’t been with the verve of, say, Sen. Elizabeth Warren, D-Mass. On the CEO pay, he’s also correct, but tax hikes on the top 1% were an essential element of President Obama’s economic policy, and he probably got about as much from the GOP as possible. And strengthening the hand of labor shoud always be a core issue for Democrats.

Democrats have achieved much during the Obama Administration. There’s hardly any disagreement that Democrats were “incompetent in conveying their actual accomplishments in economic policy,” as Kilgore writes. (Emphasis his.) Schumer was correct in stating that Democrats should display more conviction about their economic platform. What he didn’t say is that what’s been missing is the courage of their convictions.

“We must convince the middle class that the only way out of their morass is by a stronger and effective government, not by demeaning or running away from it,” Schumer told his audience. But by trampling over the Affordable Care Act, he became part of the problem.

Labor Unions Are Leading the Fight against Obama’s Trade Agenda

K. William Watson has written a post about how labor unions and not the Tea Parties are leading the fight against Obama’s trade agenda.

This week is the #StopFastTrack Week of Action, an attempt by the anti-globalization movement to coordinate protests around the world against the Trans-Pacific Partnership, a potential free trade agreement between the United States and 11 other Pacific Rim countries.  The reason they’re doing it now is to influence lawmakers in the lead up to Congress’s lame duck session, during which many in Washington hope/fear that Congress will vote on a bill to grant “trade promotion authority” (also known as “fast track”) to help the Obama administration complete the TPP negotiations.

Spearheading the effort is the AFL-CIO.  In addition to asking supporters to call their member of Congress, the unions have also paid for ads at the DC metro station on Capitol Hill, obviously meant to reach congressional staffers during their commute.

Understandably considering the source, the ads have a very union-like feel to them.  Lonely hardhats on the floor of a shuttered factory, middle-aged people lamenting that they’re not being paid enough, etc.  Here’s a typical example showing a forlorn-looking young man who’s upset about income inequality:

The “1%” rhetoric should be quite familiar to most Americans by now as the standard jargon of the ideological left when they rail against all forms of voluntary commerce.  It’s no surprise to see it employed by labor unions in their crusade against free trade.

Organized labor’s opposition to trade is nothing new.  So, in order to get more attention this year, labor groups have been readily pointing out that even some Republicans are opposed to fast track.  In particular, they are referring to a soi-disant “tea party” group that claims fast track will enable “Obamatrade” to destroy American sovereignty and jobs.   That group takes a very different approach with its messaging:

obama_promises_4

The news media have run with the narrative that a right-wing insurgency against fast track could threaten the U.S. trade agenda.

The problem with this narrative is that it is just wrong.  Scott Lincicome and I have written acomprehensive take-down of the attempt by a tiny protectionist wing of the GOP to paint its anti-trade agenda as part of the tea party movement.  Yes, there are conservatives who don’t like free trade, but the tea party movement is all about holding Republican members of Congress accountable when they stray from (most) limited government principles.  As such, the members of Congress most associated with the tea party movement have the best records in support of free trade.

Trying to get Republicans to oppose free trade by wearing a tri-corner hat and shrieking “OBAMA!!!” merely plays to the negative views of the tea party held by many in the news media.

There are real obstacles to liberalizing trade in the United States.  The greatest obstacle is the inescapable reality that politicians benefit from rigging the system in favor of narrow constituencies seeking protection.  Protectionists get ideological cover mostly from the anti-globalist left but also from the nationalist right.  Thankfully, that nationalist impulse is largely in abeyance as a force against free trade in Congress at the moment, and “Obamatrade” notwithstanding, the tea party isn’t about to bring it back.

After midterm drubbing, senior Dems voicing regret over ObamaCare

Here’s a post from Kara Rowland at FoxNews about how Senior Democrats are voicing regret over Obamacare after midterm drubbing.

A strange thing has happened on Capitol Hill. Senior Democrats who were vital in writing and promoting ObamaCare appear to be having a change of heart.

First, there was Sen. Chuck Schumer, the upper chamber’s No. 3 Democrat, who voiced regret about his party’s misplaced priorities during President Obama’s first two years in power, when they possessed a filibuster-proof majority.

“Unfortunately, Democrats blew the opportunity the American people gave them,” Schumer told an audience gathered at the National Press Club last week. “We took their mandate and put all of our focus on the wrong problem — health care reform.”

The New York Democrat punctuated his criticism with the disclaimer that health care reform was nevertheless an important issue; it just should have been a bit farther down on the to-do list.

“Americans were crying out for the end to the recession, for better wages and more jobs, not changes in health care,” he said.

But Schumer isn’t the only Democrat with buyer’s — or lawmaker’s — remorse. In an interview published Wednesday, retiring Sen. Tom Harkin of Iowa told The Hill newspaper that ObamaCare didn’t go far enough, arguing that the party should have pushed harder for a government-run, single-payer system while it had a filibuster-proof majority — or dropped it altogether.

“We had the power to do it in a way that would have simplified healthcare, made it more efficient and made it less costly and we didn’t do it,” Harkin said, according to the Hill. “So I look back and say we should have either done it the correct way or not done anything at all.”

The retiring chairman of the Senate health panel, who helped write the law, also laid blame on the White House for not pushing centrist Democrats hard enough on the so-called public option.

Harkin later told reporters on Wednesday that the law “should have been done in the first 100 days” but it “drug on and drug on and drug on.”

The remarks are striking, coming from some of Capitol Hill’s most senior and influential Democrats.

But they come after the party has suffered two midterm election drubbings — the most recent of which handed control of the Senate to Republicans — and the emergence of videos where ObamaCare co-architect Jonathan Gruber is heard claiming the law’s authors took advantage of Americans’ “stupidity.”

Since the law’s passage, ObamaCare has been a major theme of Republican campaigns and critics pounded incumbent senators for their votes in favor of the massive law, which remains unpopular among voters (the most recent Real Clear Politics average shows 52.5 percent disapproving of the law with 37.9 percent in favor).

Republican leaders were only too happy to pounce on Schumer’s remarks.

“It was fairly remarkable to have the number-three Democrat in the Senate say last week that Obamacare was a mistake,” Sen. John Thune, chairman of the Senate Republican Conference, told reporters Tuesday. “That is a really, really remarkable statement if you think about it.”

House Majority Leader Kevin McCarthy likewise declared: “I agree with Chuck Schumer.”

For their part, Democrats — including former Obama aides and a former top staffer for House Minority Leader Nancy Pelosi — didn’t hesitate to push back against Schumer’s comments.

Several noted that, as a member of leadership, he not only voted for the bill but was deeply involved in its route to passage.

“Certainly the senator’s statement was intended to appeal to Senate Democrats who might be looking for a new leader in the next few years,” wrote former Pelosi Chief of Staff John Lawrence, who challenged Schumer’s suggestion that the Affordable Care Act only benefited a small percentage of the electorate in a blog post. “It just wasn’t necessary, in order to prove he has their backs, to put a dagger into the backs of President Obama and Democratic congressional leaders.”

In a tweet, former Obama speechwriter Jon Lovett pondered: “So what exactly does Chuck Schumer believe was the error? Does he believe that the goal of winning office is winning office?”

Asked about the fact Republicans are using his comments against him at a Tuesday media availability, Schumer didn’t walk them back but pointed out that his entire speech was some 20 pages long. That’s “all I’m going to say on that issue,” he said.

But if Schumer was right in his post-mortem that Democrats failed to prioritize economic issues, Thune argued the party has not learned the lesson.

“Ironically, the Dems now are talking about issues like immigration, climate – things that get very far afield from the issues that I think the American people care the most about, which is jobs, the economy and how to make their futures better and brighter,” the South Dakota Republican said.

Capitol Attitude is a weekly column written by members of the Fox News Capitol Hill team. Their articles take you inside the halls of Congress, and cover the spectrum of policy issues being introduced, debated and voted on there.

‘Healthy Utah’ Obamacare Expansion: Worse Than Expected

A post by Jonathan Ingram, Nic Horton and Josh Archambault— Mr. Ingram is Research Director, Mr. Horton Policy Impact Specialist, and Mr. Archambault a Senior Fellow at the Foundation for Government Accountability.

After months of secretly negotiating a backroom deal with the Obama administration, Governor Gary Herbert (R-UT) has finally released (some of) the details of his Obamacare expansion plan. We’ve not hesitated to share our disappointment over Herbert’s recent actions to bring Obamacare to Utah (which has always seemed out of character for him), but we’ve also met with the governor and his chief of staff privately to share our concerns about this welfare program. Sadly, Gov. Herbert continues to move forward with an Obamacare expansion plan that is bad for taxpayers and the truly needy.

Earlier this morning, Gov. Herbert released more details about his plan to expand Obamacare in Utah. Unfortunately, a careful examination of the plan reveals that Herbert’s rhetoric rings hollow. Several members of the legislature’s Health Reform Task Force expressed deep concerns during the presentation by the Governor’s office.

They’re right to be worried: like any other Obamacare expansion, his plan will create a new entitlement for able-bodied adults, discouraging work and trapping more Utahans in poverty and government dependency.

Utah Governor Herbert

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Utah Governor Gary Herbert (R) and UDOH Executive Director Dr. David Patton speak about Healthy Utah. (Photo: KCPW)

Just Another Obamacare Expansion

Although the Governor insists his plan is not an expansion of Medicaid under Obamacare, the details of his plan make clear that it is nothing more than an Obamacare expansion in disguise.

Herbert’s plan would deliver the same required benefits as Medicaid and be subject to the same cost-sharing limits as Medicaid. Cost sharing in Healthy Utah would actually be even lower than the nominal levels Medicaid allows. Healthy Utah benefits would be delivered through Obamacare-compliant plans sold on the Obamacare exchange and the state’s Avenue H exchange.

The plan would cover the exact same able-bodied adults as the optional Medicaid eligibility category created by Obamacare. Those enrollees would be legally classified as Medicaid enrollees, making them entitled to all the same rights and protections as any other Medicaid enrollee. The plan would operate under a Medicaid waiver, would need an amended Medicaid state plan to implement and would be funded through the Medicaid program.

Adding bows and ribbons and calling it “Healthy Utah” doesn’t change its fundamental nature as an Obamacare expansion. And Herbert wouldn’t be pursuing this option at all if the Obama administration wasn’t making him empty promises of “free” Obamacare dollars. He’s so anxious to get those dollars that he’s even proposing to expand traditional Medicaid “temporarily,” until his “Healthy Utah” plan wins federal approval and is able to be implemented.

Nothing New To Utah

Gov. Herbert has consistently said that he is “trying to make lemonade” out of Obamacare lemons by crafting a “Utah-specific” plan. Rather than making lemonade, the Governor appears to have been drinking the Obamacare Kool-Aid. The “Utah-specific” plan is nothing more than old policy failures copied-and-pasted from other states.

Herbert’s “Utah-specific” idea of using health plans sold on the Obamacare exchange to provide this new entitlement class with Medicaid benefits is copied from Arkansas and Iowa, where the policy has been a failure. In Arkansas, costs have run over budget every single month and state lawmakers are poised to repeal the plan. In Iowa, state bureaucrats have already asked for more money from Washington and had to move thousands of adults out of the waiver and into traditional Medicaid after half of the participating insurers hiked premiums 20 percent and dropped out of the plan.

His other “Utah-specific” ideas were also recycled from these failed experiments: the idea to impose nominal, non-enforceable “premiums?” Taken from Iowa and Pennsylvania. The idea to have a completely voluntary work assistance program? Taken from Pennsylvania and Indiana. If Utah lawmakers were hoping for a “Utah-specific” plan, they’re sure to be disappointed.

No Work Requirement

We have repeatedly predicted that Gov. Herbert’s final “Healthy Utah” deal would contain no meaningful work requirements, despite the fact that he promised he would never budge on this provision. We didn’t have a crystal ball; we just had the good sense to watch how other Obamacare expansion negotiations have unfolded across the country. So it was no surprise when he quietly announced the previously “non-negotiable” work requirements had been watered down to “work effort” provisions.

Now we learn (and it comes as no surprise) that there is absolutely no work requirement in the final Obamacare “deal” Gov. Herbert has struck with President Obama. Worse yet, there’s not even a requirement for able-bodied adults to engage in “work effort” activities. Instead, the plan simply calls for a voluntary program that allows enrollees to use state services to help find work or improve their skills if they’re interested. Enrollees would face absolutely no Medicaid-related consequences for refusing to participate in the program. They won’t lose eligibility; they won’t pay higher premiums, nor will they be subject to any other related “penalty.”

State bureaucrats are “considering” other options, such as making eligibility for unrelated state-funded welfare programs contingent on participation. However, such a provision would be toothless, as the vast majority of Obamacare expansion enrollees have never qualified for those other types of welfare programs to begin with.

We predicted this exact result when we commented on the plan in October. At the time, the Governor publicly called us liars. But the truth is now plain to see: able-bodied adults won’t be required to work in order to receive welfare under Herbert’s Obamacare expansion plan.

No Premium, No Problem

Gov. Herbert has repeatedly promised that enrollees in his Obamacare expansion plan would have significant “skin in the game” in the form of monthly premiums. But these so-called “premiums” are far less than advertised: individuals enrolled in Healthy Utah who are below the federal poverty level will pay no monthly premium whatsoever, while those above the poverty line will (in theory) pay up to $15 per month.

Gov. Herbert promised these premiums would be the same as on the exchange, but the reality is that they’re significantly lower. For comparison, those same individuals would pay $44 per month for the benchmark plan in the Obamacare exchange. Instead, they’ll pay $15 – if they choose to pay anything at all.

The “required premiums” have become nothing but mere suggestions. Nothing in the plan creates any sort of meaningful penalty for those refusing to pay their monthly premiums. Even if the state gets permission to disenroll those who fail to pay their premiums, these adults will be allowed to re-enroll immediately, as nothing in the plan proposes any sort of lock-out period of other penalty. In fact, some enrollees may even use this strategy to switch plans in the middle of the year if they find that they don’t like the one they picked.

No Meaningful Cost Sharing

Gov. Herbert promised his plan would have stronger cost sharing than traditional Medicaid, but a closer inspection reveals this as just another empty promise. Individuals below 40 percent of the federal poverty level will pay absolutely no cost sharing whatsoever. For those between 40 percent and 100 percent of the federal poverty level, out-of-pocket costs will be capped at $200 per year. For those above the poverty line, out-of-pocket costs will be capped at just $400 per year. In each of these groups, cost sharing is actually significantly lower than traditional Medicaid allows.

One of the strangest promises Gov. Herbert made was his promise that Healthy Utah would charge $50 copayments for all unnecessary emergency room use. That was a strange promise, given the fact that Iowa and Pennsylvania were both denied permission to charge just $10.

Instead of imposing a standard $50 copayment, the Healthy Utah plan would give some enrollees with incomes above the federal poverty line the option to select plans with $50 copayments for non-urgent ER use. Those who pick those plans would get a $5 monthly discount on their monthly premiums, but total out-of-pocket costs for either plan would be the same – at most, $400 per year. So even if individuals opted into that plan, they’d only be subject to the copay a maximum of four times.

Overall, the majority of enrollees wouldn’t even have the option to pick the higher-copay plan and it’s unclear how many people would opt to select the plan with higher copays in exchange for lower premiums, knowing that the premium requirement would be practically unenforceable.

New Welfare Cliff

Gov. Herbert also promised a “smooth transition” between Healthy Utah and the Exchange, but this design actually creates a massive welfare cliff. Able-bodied adults on the Healthy Utah plan would pay at most $120 to $180 per year in premiums. Enrollees who earn an extra dollar and lose their Healthy Utah eligibility would be subject to $531 per year in premiums for the benchmark plan in the Obamacare exchange. Able-bodied adults on the Healthy Utah plan would pay at most $400 in copayments, coinsurance and other out-of-pocket costs.

Moving from Healthy Utah to the Obamacare exchange would increase out-of-pocket costs to $2,250.

Practically speaking, this means an individual who earns a single dollar more than Healthy Utah eligibility limits, and therefore leaves Healthy Utah to enter the Obamacare exchange, could have their premiums and total out-of-pocket costs go up by as much as $2,300. That’s hardly a “smooth transition.”

Brace Yourself For Backpedaling

Even though Gov. Herbert says his expansion plan is a done deal, the truth is that there is much left to negotiate with the Obama administration.

At this point, the Obama administration has simply told the state that the plan is “approvable in concept.” The state will still need to submit a formal waiver request to the federal government, hold public comment periods and negotiate the final terms and conditions of the waiver. Nothing in this “deal” is legally binding at this point, meaning that the federal government can come back later and water down Herbert’s plan even further, after the legislature would have already signed off on the proposal.

The Herbert administration even says it has not yet written a formal waiver request, which could take several months to finish. By only sketching out the broad aspects of the plan, it seems the Governor is hoping for a blank check from the legislature.

This is exactly the scenario that has played out in other states, including Iowa and Indiana, even when the legislature sets pretty clear terms about what they’re approving.

Would Herbert be willing to walk away from the negotiating table if President Obama calls his bluff and tries to water down the proposal even more?

Time To Reject Obamacare Expansion Once And For All

The good news is that Gov. Herbert has absolutely no legal authority to expand Medicaid under Obamacare. Instead, this proposal will go to the legislature next year, which will need to carefully consider the plan (and its policy failures) before taking action. Members of the Health Reform Task Force expressed some pretty serious reservations about Gov. Herbert’s Obamacare expansion plan, warning that the full legislature would need to proceed very cautiously as it reviews the full plan.

Any decision they make to expand Obamacare will have profound impacts on the future state budget, shrink the economy, undermine marriage and negatively affect the state’s unique culture of neighbors helping neighbors. Instead of spending time debating how to tweak Obamacare expansion, lawmakers should reject the expansion outright and continue its efforts to decrease the cost of care, making health care more affordable for everyone.

The federal government has once again demonstrated how disinterested they are in real flexibility for states. Gov. Herbert should keep his word to Utahans and walk away before it’s too late.

How to finally kill Obamacare

Thanks to four justices of the Supreme Court, there is now a clear path to repealing and replacing the Affordable Care Act next year, finally bringing Obamacare to an end.

But Republicans won’t accomplish this by waiting for the court or just voting to repeal the law one more time. The only way they can succeed is by crafting their own replacement — and they need to start right away.

Until the Supreme Court agreed to hear King v. Burwell, which challenges the legality of the IRS rule allowing Obamacare subsidies in states that have not built their own insurance exchanges, the conventional wisdom was that Congress would pass a symbolic bill to repeal Obamacare that everyone knows would be vetoed by the president. Then they’d move on. Obamacare would survive at least until 2017.

But the decision to hear King changes everything. Insiders know that this challenge has a decent chance of success. Rather than asking the court to establish some grand constitutional principle, the justices are merely being asked to hold the IRS to the actual wording of the law, which is not nearly so heavy a lift.

Financial risk

The eventual outcome of the case doesn’t matter as much as the decision to hear it.With the lawsuit now looming over them, all the “stakeholders” — such as insurance companies and health care providers — know that the subsidies for health insurance in36 states are in serious jeopardy. And the end of these subsidies means the end of the insurance mandate for businesses in those states, which kicks in only if employees are eligible for subsidies on an exchange.

Insurance and health care companies need an insurance policy against the collapse of the insurance market. Republicans in Congress need a way to resist the enormous political pressure that will be applied to simply “fix” the health care law by allowing subsidies to flow through the federal exchange. And Democrats need to salvage something from all their efforts to pass the law.

Repeal, replace

In short, now everyone needs to invest in devising a replacement for Obamacare. Even better, by developing such an alternative, Republicans can make a favorable ruling more likely.

As a rule, Supreme Court justices are reluctant to invalidate a law on which many relied. It will be far easier for the justices to enforce the law’s existing language if they know there is a viable alternative that can be enacted by both houses of Congress and signed by the president within a week of their ruling.

To devise such a replacement, the Senate and the House must use “regular order” and their committees to do actual legislating with input from the Democratic minority.

Because everyone will now know that their handiwork may very well become law, everyone has an incentive to take this project seriously.

The first line of any such bill should be the complete repeal of each and every word of the Affordable Care Act. This monstrosity must not be allowed to survive in any form. In its place, the new Congress should write a replacement bill that would:

Restore the private insurance market using actuarially based insurance pricedaccording to risk. For example, young people would pay much less than older people.

Restore consumer choice to buy true private insurance limited to the terms they want to pay for, including policies insuring only against the catastrophic health care costs, andmedical savings accounts.

Increase competition by allowing state-regulated insurance to be sold across state linesso consumers can keep their policies when moving from one state to another.

Increase equity by extending the tax benefits now available only to employer-based insurance to all health insurance. Like car insurance, you shouldn’t have to change health insurance policies when changing jobs.

With the Democrats now in the minority, such a bill is very likely to be bipartisan if it contains a “refundable” tax credit for health insurance for all Americans, regardless of income — essentially extending to everyone the very subsidies that the court will strike down.

By participating in the process, not only can they ensure that subsidies are included, they also can claim victory. Rightly or wrongly, Democrats can say that, without it, Republicans would never have supported reforming the previously dysfunctional health insurance system.

Visible alternative

With or without bipartisanship, however, Republicans need to have a well-vetted replacement in the pipeline. To make a favorable ruling in King more likely, the legislative wheels must be visibly in motion by the time of oral arguments in March.

Before the Supreme Court took this case, Republicans in Congress were limited to symbolic action against Obamacare. Now, thanks to voters in November and the justices who voted to hear the case, beginning in January, Republicans in Congress can craft a bipartisan market-based replacement that the president will be compelled to sign in June when the court announces its decision. Simply by acting as legislators, Republicans in the next Congress can actually repeal and replace Obamacare.

Randy Barnett, a Georgetown University law professor, directs the Georgetown Center for the Constitution.

CORRECTION: An earlier version of this story misstated the number of states that may lose subsidies under the King v Burwell Supreme Court case. The correct number is 36.