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“If this warmed-over substitute for government-run health care remains unchanged, the Club for Growth will key vote against it,” said the group’s president, David McIntosh, referring to a process in which lawmakers are graded on their votes, the better to use them as ammunition on the campaign trail.
The dilemma Republican congressional leaders face is, if they change the legislation to appease hard-line conservatives, they are likely to alienate more-moderate members who are wary of disrupting insurance markets and taking coverage away from those who gained it under the ACA.
The margin for dissent is slim: Assuming no Democrats break ranks to support the bill, for the overhaul to pass, Republicans can lose only 21 votes in the House and two votes in the Senate.
Four key Republicans in the Senate have expressed worries about the plan’s possible impact on lower-income people who received Medicaid coverage through the ACA’s expansion of that program. The four senators are split on exactly what proposals would meet their standards, but none are likely to support the course of action favored by many conservatives — passing a 2015 bill that repealed key ACA provisions without immediately including replacement provisions.
There were some signs of hope for the House plan Tuesday. President Trump offered an early boost to GOP leaders with a morning tweet: “Our wonderful new Healthcare Bill is now out for review and negotiation. ObamaCare is a complete and total disaster — is imploding fast!”
Vice President Pence attended a Senate Republican policy luncheon Tuesday and, in a break with normal practice, joined Senate Majority Leader Mitch McConnell and other GOP leaders at a news conference afterward to defend the House approach as “the framework for reform.”
“We are certainly open to improvements and recommendations in the legislative process, but this is the bill, and the president supports the American Health Care Act,” he said. “We are looking forward to working very directly with leadership in the House and the Senate in the weeks ahead. We are very confident that the American Health Care Act, with their help, will be on the president’s desk.”
In another sign of the administration’s support, Health and Human Services Secretary Tom Price sent a letter Tuesday to the chairmen of the two House committees processing the legislation, calling it a “necessary and important first step toward fulfilling our promises to the American people.”
But Price, who authored a similar ACA replacement proposal when he served in the House, said that achieving all of Trump’s health-care goals “will require more than what is possible” in the current legislation, which is limited in its scope to take advantage of special budget rules allowing for easier Senate passage.
He specifically mentioned allowing insurance to be sold across state lines, pharmaceutical cost reductions and “medical legal reforms,” an apparent reference to long-standing GOP proposals to limit malpractice liability.
Senate Majority Leader Mitch McConnell (R-Ky.) offered measured support for the proposed legislation and said he would bring it to the Senate floor should it pass the House.
“I encourage every member to review [the legislation] because I hope to call it up when we receive it from the House,” McConnell said Tuesday on the Senate floor. “We’ve come a long way. We’ve got a lot further to go, but we’re making significant progress. Working arm in arm with the House and the new administration, we’re going to keep our promise to the American people.”
While some of the fiercest criticism came from hard-right activist groups that have dogged Republican congressional leaders for years, other more establishment-minded organs joined the chorus of dissent.
National Review published an editorial Tuesday that said the legislation was “a disappointment” and has “serious flaws even as a first step toward full repeal and replacement.”
Republicans, the influential conservative magazine said, “would be better off rallying behind a bill in which they really believe, even if Democrats kill it with a filibuster,than trying and failing to enact a bill that they support only tepidly.”
Leaders involved in drafting the bills sought to defend their plan against the onslaught of criticism, describing it as the product of months of internal discussions and saying its details could still change.
“We now have a bill that’s available for all to read,” said Rep. Greg Walden (R-Ore.), chairman of the House Energy and Commerce Committee, which helped craft one of them, at a news conference Tuesday. “I’d encourage them to do it. I’d encourage them to look against their own bills and what they’ve supported in the past. And then let’s have a thoughtful legislative discussion.”
Rep. Kevin Brady (R-Tex.), chairman of the House Ways and Means Committee, which produced the other bill, said: “As Republicans, we have a choice. We can act now, or we can keep fiddling around and squander this opportunity to repeal Obamacare and begin a new chapter of freedom for the American people. House Republicans are choosing to act now.”
Still, agitation among conservatives was evident Monday night and poured into Tuesday.
“Keep the ‘Cadillac’ tax in place? Keep Medicaid in place until 2020?” said Rep. Jim Jordan (R-Ohio), a co-founder of the House Freedom Caucus, referring to high-priced health-care plans. “We didn’t have Medicaid expansion in the bill we sent to President Obama, but we have it in the one we send to President Trump? That makes no sense to me.”
“Obamacare 2.0,” tweeted Rep. Justin Amash (R-Mich.), a libertarian who frequently breaks with GOP leadership.
Under two bills drafted by separate House committees, the government would no longer penalize Americans for failing to have health insurance but would try to encourage people to maintain coverage by allowing insurers to impose a 30 percent surcharge for those who do not have continuous coverage.
The legislation would preserve two of the most popular features of the 2010 health-care law, letting young adults stay on their parents’ health plans until age 26 and forbidding insurers to deny coverage or charge more to people with preexisting medical problems. It would also target Planned Parenthood, rendering the women’s health organization ineligible for Medicaid reimbursements or federal family -planning grants — a key priority for antiabortion groups.
Taken together, the bills introduced Monday represent the Republicans’ first attempt — and best shot to date, with an ally in the White House — to translate into action seven years of talking points about demolishing the ACA.
At the same time, major aspects of the House GOP plan reflect the treacherous terrain that Republicans face to win enough votes within their own conferences in the GOP-controlled House and Senate.
The bills must address concerns of both conservatives worried about the plan’s cost and the notion it might enshrine a new federal entitlement, as well as more moderate members who want to ensure that their constituents, including those who received coverage under the ACA’s Medicaid expansion, retain access to affordable health care.
The Freedom Caucus, a block of roughly 30 House hard-liners who criticized earlier versions of the bill, is set to meet Tuesday night to discuss the health-care bill and perhaps develop a list of demands to present to GOP leaders.
Members of the Republican Study Committee, a larger conservative group, were already critical of key elements of the plan. “This is a Republican welfare entitlement,” reads an RSC analysis distributed late Monday, addressing the inclusion of refundable tax credits in the plan.
With no Democrats expected to vote to pass the bill and four House GOP seats vacant, Republicans can afford to lose no more than 21 members in the lower chamber.
In recognition of the close vote that is expected, House Majority Whip Steve Scalise (R-La.) and several deputy whips are expected to visit the White House Tuesday afternoon to discuss the health-care bill with Trump administration officials.
On Tuesday morning, Trump signaled the work on the proposal was not completely finished, referring to selling insurance across state lines and saying that change would come in “phase 2 & 3 of healthcare rollout.” The president also said he was “working on new system where there will be competition in the Drug Industry” that will lead prices to “come way down.”
Conservative critics of the measure had noted the plan’s exclusion of selling insurance across state lines. “The problems with this bill are not just what’s in it, but also what’s missing,” said McIntosh.
Yet attacks from the right were not the only challenge facing Republican leaders.
Four key Republican senators, all from states that opted to expand Medicaid under the ACA, said they would oppose any new plan that would leave millions of Americans uninsured.
“We will not support a plan that does not include stability for Medicaid expansion populations or flexibility for states,” Sens. Rob Portman (Ohio), Shelley Moore Capito (W.Va.), Cory Gardner (Colo.) and Lisa Murkowski (Alaska) wrote in a letter to McConnell on Monday.
The plan from House Republicans would substantially redesign Medicaid with the goal of balancing the GOP’s antipathy toward the ACA’s expansion of the program against the concerns of a significant cadre of Republican governors — and the lawmakers from their states — who fear losing millions of dollars that the law has funneled to help insure low-income residents.
Democrats, meanwhile, have given no indication that they intend to work with Republicans, and top party leaders decried the GOP plan Monday as a betrayal of everyday Americans. “Trumpcare doesn’t replace the Affordable Care Act, it forces millions of Americans to pay more for less care,” said Senate Minority Leader Charles E. Schumer (D-N.Y.).
In particular, the plan to target Planned Parenthood has already generated fierce pushback from Democrats and doubts from some Republicans who have noted that federal funds are already barred from funding abortions and that Planned Parenthood provides routine medical care to millions of American women.