Gridlock Ensures Health Care Will Be A Pivotal Issue In The 2020 Election

April 07-- Apr. 7--WASHINGTON -- In a revealing moment even for this irrepressible president, Donald Trump last week told donors and Republican members of Congress that "we blew it" on health care, that Democrats "owned" the issue and "we have to take that away from them."

"We have to protect and cannot run away from a thing called 'pre-existing conditions,'" the president said at the National Republican Congressional Committee's annual spring dinner, adding: "If you don't support it, you have no chance of winning."

Left unsaid was this fact: After Republicans failed to repeal and replace the Affordable Care Act during the president's first two years in office, Trump has directed the Justice Department to support a lawsuit, brought by Missouri and 19 other states, challenging the law's constitutionality.

If successful, it would strike down the pre-existing conditions protection along with other popular parts of the law, including a provision that allows children to remain on a parent's health insurance plan until age 26. A federal judge in Texas in December ruled the law's individual mandate unconstitutional, which would effectively kill the law known as Obamacare if higher courts agree. The case is expected to be decided by the U.S. Supreme Court, which has a conservative majority.

Republicans hope legal appeals linger beyond the 2020 elections, when Trump promised he would make the GOP the "party of health care" even as he and his party struggle to come up with a cohesive plan to replace the law.

So Americans who face rising premiums and deductibles shouldn't count on any comprehensive solutions out of Congress for the next two years.

Some lawmakers, like Sen. Josh Hawley, R-Mo., are taking piecemeal approaches. Hawley last week signed on to a bill to try to lower prescription drug prices.

For nine years, Democrats have urged Republicans to come up with something better if they insisted on scrapping Obamacare. At the same time, Democrats have allowed problems with the existing law, such as declining insurance choices and higher costs, to linger.

And now, some Democratic presidential candidates are pushing "Medicare for All," which would provide universal health care coverage. That's something former President Barack Obama rejected as politically impossible when he pushed through his namesake legislation in early 2010.

Senate Majority Leader Mitch McConnell, R-Ky., who oversaw an unsuccessful GOP push to partly repeal the Affordable Care Act in 2017, is bearish on getting much done while the legal challenge works its way through federal courts.

McConnell said he told Trump that he was fine with efforts to lower prescription drug prices, but "not a comprehensive effort to revisit the issue that we had the opportunity to address (during) the last Congress, and were unable to do so."

Weariness with the health care debate has set into Republican policymakers, many of whom say the ball is now in the courts' court.

"It is a little early for us to assume that that is the case," said Sen. Roy Blunt, R-Mo., of the potential of higher courts striking down the law altogether. "The court of appeals will look at all of the evidence that led the case to that point, and decide if they agree with the lower court, or not, and we will see what happens. It is really too early for us to know what the court is going to say."

So, nine years after its passage, Obamacare remains as politically contentious as ever.

Sick over health care

In a survey released Tuesday, the same day Trump spoke to GOP donors, Gallup reported that 3 in 4 Americans believe they pay too much for health care relative to the quality they receive. Almost half said they feared a major health challenge could drive them into bankruptcy.

Strikingly, three-fourths of the respondents to the survey, which Gallup did in conjunction with the advocacy group West Health, said they feared that rising health care costs could do "significant and lasting damage to the U.S. economy."

"Part of the anxiety is that there is so much turmoil over the policy," said Timothy McBride, co-director of the Center for Health Economics and Policy at Washington University's Brown School. "Politicians continue to debate this issue. The issue seemed to be settled, but then they keep saying, 'Well, we might repeal that law and replace it.' That is part of it.

"And then I think the health care markets are really a bit in turmoil as well," McBride continued.

He chairs the Missouri HealthNet Oversight Committee. State officials recently announced that 70,000 people had been taken off Medicaid in Missouri, making the Show-Me state having one of the largest drops in coverage for the poor.

Some state officials attributed that to a better economy, although McBride said it was from more complex factors, including an "antiquated" state computer system and communications problems between the state and Medicaid recipients.

A familiar divide

Most of the 20 states that have challenged the law in federal court have significant rural populations.

McBride, who wrote his college dissertation on Social Security and has worked on federal benefits policy for more than 30 years, says that in general, the insurance marketplaces under Obamacare have worked far better in urban areas than in rural areas.

The marketplaces "have been sort of the lightning rod, attacked a lot" by Republicans, McBride said.

"About two-thirds of the counties in the country are rural, but not that many people live in rural areas," he said. "It is really hard to make insurance work in rural areas, because there are so few people. But the truth of the matter also is the marketplaces are working pretty well in urban areas."

Both Blunt and Hawley sprinkle their observations about Obamacare with anecdotal stories about Missourians, many in rural areas, whose premiums and deductibles have gone so high so as to practically not be covered by insurance.

McBride said that has, especially been the case for those whose incomes three or four times the poverty level; those closer to the poverty line and those who get covered by Medicaid have done better, he said.

This rural-urban divide is a major storyline of the Trump presidency.

He won the White House, in part, by piling up huge margins in rural areas of re-emergent swing states such as Wisconsin, Pennsylvania and Michigan, all that have significant rural populations.

But last year his party lost control of the House, in large part because voters saw the GOP attacking an Obamacare that seemed to be working better in the suburbs and cities. Republican voters were unhappy that the Congress their party controlled didn't follow through on a promise to repeal and replace Obamacare.

A piecemeal approach

Hawley and Sen. Rick Scott, R-Fla., have introduced legislation requiring more flexibility and transparency in drug pricing. It also would prevent Americans from paying more for drugs that are priced lower in Europe or Canada or other foreign countries.

Hawley cited the case of a blood-thinning drug, one of the 20 most-prescribed drugs in the U.S., that he said cost people in Versailles, Mo., five times what people paid in Versailles, France.

"It isn't fair and it isn't sustainable," Hawley said, "and people simply can't afford it."

But Hawley was comparing prices in a country with a degree of socialized medicine. And the bill that he and Scott are pushing takes a decidedly un-Republican price-control approach.

"I know some critics will say that that is too much government interference in the free market," Scott said. "I am a strong believer in free-market capitalism. ... But this is ridiculous. There is no reason these drug prices should be going up like this."

Trump had identified several Republicans, including Scott, whom he said were putting together a GOP plan. But Scott said he's focusing right now on drug prices.

Hawley, asked if he felt there was a moral responsibility for him and other state officials who had launched the lawsuit against Obamacare to come up with a comprehensive replacement, said essentially the same thing.

"We want to act right now to bring down prescription drug costs, right now," he said. "That is regardless of what happens with Obamacare. What is abundantly clear is that Obamacare has failed."

As to protecting pre-existing conditions should Obamacare be struck down?

"I am at work on that," Hawley said. "We will have more to say on that."

But as a measure of the ever-shifting sands of health care policy, the Scott-Hawley bill has a provision ending it after five years.

"We are going to find out, 'Does this work?'" Scott said.

Democrats stand aside

Despite lingering problems in the Obamacare marketplaces and higher-than-promised prices for some Americans, Senate Democratic Leader Chuck Schumer has taken a let-them-twist-in-the-wind attitude.

Democrats have been bolstered by polls showing that, after years of being unpopular, a slight majority now favor Obamacare. The latest Kaiser Family Foundation survey showed 50 percent approving, 39 percent disapproving. In July 2014, 53 percent disapproved, 37 percent approved.

Schumer said Trump's support of the lawsuit challenging Obamacare "reeks of desperation."

"They have no backup plan," he said. "The president and Republicans are for repeal. They have no replace."

These are the raw politics of this intensely personal issue, one that goes to the heart of every American's views of government vs. private initiative.

In the five elections since its passage, each side has used the issue to rile up their bases. Neither side, backed up by hundreds of millions of dollars in campaign donations from all angles of the industry and the ideology of health care, sees an immediate electoral advantage to work with the other.

McBride said Congress has almost always in the past revisited major pieces of legislation to address unintended consequences or plug unforeseen holes that have arisen.

But not Obamacare.

"They have never been able to pass an Affordable Care Act revision bill because there is so much contention over it," he said. "Republicans only want to repeal it. The Democrats want to pass revisions and the Republicans won't let them.

"We should be fixing what is wrong with it," McBride said, but "they want this for a campaign issue."

"If we were making logical health policy, we would be fixing the corners of the bill," he said, adding that "every health care analyst in the country could give you a list of 20 things that we think should be done to the bill."

"But this is just too much political fodder. And both bases are guilty of it."

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