It's as if everyone in Washington has given up on the idea of practical governance in favor of posturing for the benefit of their core political base.
A hurricane's projected landfall is an example of a true deadline, one that really means do or die. September 30th, the date after which the Republican Senate can no longer use the budget reconciliation process to push through health care legislation by a simple majority, is an example of an artificial deadline — one that is about politics, not about improving anyone's health care.
It's easy to see where Republicans' urgency about making that deadline comes from. They are looking across the aisle at Bernie Sanders, who is drawing "Amens" for the concept that Medicare-for-all is the only way to achieve universal coverage, and pondering how they might negotiate anything with these Democrats.
The GOP's fear is palpable. Republicans in Congress are getting an earful from constituents who've swallowed endless lies from them about Obamacare since before its passage, folks who are hooked into a media echo chamber that can easily spawn GOP primary opponents
to better conform to the party's "repeal and replace" promise.
Another fabricated sense of urgency surrounds the idea that Obamacare's markets are rapidly crumbling. In fact the Congressional Budget Office makes it clear in a report last week
that it's Trump himself who is destabilizing the ACA marketplaces.
Trump's Department of Health and Human Services is cutting 90% of the budget
from its enrollment campaign for 2018 (I'll advise you that open enrollment is November 1st through December 15th).
Such efforts to cut down the customer base of ACA insurance plans are a key reason premiums will go up in 2018, and the other key factor -- cited in an analysis
of proposed insurance prices by the Kaiser Family Foundation -- is all of the President's talk about not fulfilling the law's requirement to distribute subsidies to insurers, part of the law's careful balancing of risk that keeps insurers willing to play along.
Yet despite the administration's best efforts, as of today every single county in the United States has an insurer
offering plans on the ACA marketplace. That's the single most powerful crystallization of the law's careful balancing of capitalism and public utility. All of these companies have a choice, and they ultimately choose to sell insurance on the marketplaces because they prefer to make money.
Of course, this situation can only hold so long under the weight of a four-year, post-truth presidency enabled by a Republican Congress.
Which brings us to the post-truth Graham-Cassidy repeal bill currently on offer.
If it collects 50 Republican senators who are irresponsible enough to sign on without a CBO score, it would surely get a tie-breaking vote from the Vice President, a rubber stamp in the House and an instant signature by the President.
"If a politician controls the dollar, the system lines up to serve the politician," Sen. Bill Cassidy (R-LA) stated at his September 13 press conference discussing the bill
. "If the patient controls the dollar, the system lines up to serve her. The theme of what we are trying to do is to give the patient the power."
I'm not aware of any politicians who've lined their pockets thanks to Obamacare. As an informed citizen, I don't know what Senator Cassidy is talking about.
But as doctor, I can tell you this: Cassidy's bill fails his own "Jimmy Kimmel Test,"
the promise he made to the late-night host whose son was born with a congenital heart defect, receiving very expensive care at Cedars Sinai.
Cassidy said he'd only support legislation if a "child born with a congenital heart disease (would) be able to get everything she or he would need in that first year of life" even if costs exceed "a certain amount."
The patient is in fact powerless under the Cassidy-Graham bill, which gives the states block grants to administer healthcare for the poor and disabled, under whatever mechanisms they wish, and near complete freedom to enact their own rules with regards to the quality of private insurance plans sold in their states.
Most importantly, states can let insurers charge what they like to cover sicker individuals. Kimmel's son, despite his heart condition, won the birth lottery in that his future access to healthcare isn't in question — his father is rich.
But the Jimmy Kimmel test is supposed to apply to everyone. Most Americans with congenital heart defects can easily find themselves priced out of insurance plans that weigh medical risk factors.
To people with health conditions to manage, the United States would no longer be a place of free movement and opportunity. They would become a second tier of the citizenry, constrained by the limitations of a very different, balkanized land.
President Trump, too, promised Americans
he'd replace Obamacare with a system that still guaranteed people with pre-existing conditions access to good coverage. "I am going to take care of everybody. I don't care if it costs me votes or not," Trump told "60 Minutes
" while campaigning for the office.
After the election, he told the Washington Post, "There was a philosophy in some circles that if you can't pay for it, you don't get it. That's not going to happen with us."
But President Trump's and Senator Cassidy's sunny promises bear no relation to the Graham-Cassidy disaster that's bearing down on the United States.
For the President, his behavior surrounding an ACA repeal is no different than his unreal stance on many other critical policy debates. On DACA, he also promises something better than the rules now in place, but similarly he's ginned up urgency
by issuing a deadline by which he'll revoke the current presidential policy.
Just like with Obamacare, he's trying to save the nation from a disaster he's creating, a feat of propaganda that only works on those trapped in his echo chamber.
As for congressional Republicans like Bill Cassidy, they need to serve the needs of the people in their states, not their personal ideologies. Cassidy could start by listening to Louisiana's Department of Health Secretary, Dr. Rebekah Gee, who wrote the Senator
(himself a physician) about his bill's impact on their shared state.
She points to Louisiana's "high burden of extreme poverty," that necessitates a strong Medicaid program and how the bill allows insurers "to charge individuals more based on age and health status (which) would inevitably increase the cost of care for those who need it the most -- likely driving these individuals out of the workforce and into the increasingly tattered safety net of public assistance."
Gee's letter talks about the real people Obamacare is helping right now. Republicans and Democrats would do well to work on improving this law together, which is well made enough that it keeps ticking along, doing its core job. Such real work of governance gets fewer retweets than declarations of ideological purity, but a bit less fervor from the fan base is a small price to pay for the greater good of the country.