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Line of the Day (Better Care Reconciliation Act of 2017 Edition)

health-costs-money-stethoscopePeter Suderman writing about the Senate health care bill at Hit and Run:

In other words, it is exactly what critics predicted: a bill that, at least in the near term, retains weakened versions of nearly all of Obamacare’s core features while fixing few if any of the problems that Republicans say they want to fix. It is Obamacare lite—the health law that Republicans claim to oppose, but less of it. It represents a total failure of Republican policy imagination.

The piece is a good run-down of how the Senate bill is what Suderman calls “Obamacare lite.”  Regardless of what one thinks about Obamacare as a policy solution, the Senate bill is yet another example of the bankruptcy of the Republican position on this topic.  This is noteworthy because the party has been claiming it has a better approach to health care policy since the Affordable Care Act first was signed into law.  They have repeatedly claimed the need to “repeal and replace” and yet, given the opportunity to do so has demonstrated a dearth of actual ideas and solutions.  Rather, the only principles on display appear to be a desire to cut taxes on upper earners.

That’s it.

And, quite frankly, if that is what the party is, that is what the party is. But, that isn’t what they have been saying. All of which, by the way, is made worse by the fact that a lot of changes are deferred for years.  The bill, if passed, would create more, not less, uncertainty and instability in our health care system.

Part of me is not surprised that congressional Republicans have no vision in this area of policy, if anything because they have not demonstrated much in the way of policy imagination, to use Suderman’s term, for some time.  Indeed, the degree to which the GOP has been dedicated to actual governance has been questionable for some time, except for their dedication to the notion that tax cuts are the solution to all policy problems.  Still, part of me is astounded that there has been so very little in the way of some kind of conservative counter-proposal to the ACA.  Of course, part of the problem is that the ACA really isn’t an especially liberal solution (speaking in historic US political usage of the term). Some of its design emerges from conservative-oriented proposals and, further and more importantly, the basic infrastructure of Obamacare was build on a system of employee-based private insurance.  It did not radically change the pre-ACA system, rather it just grafted on elements to try and expand coverage.

I would note, too, the amateur nature of the current White House is part of the problem:  there is no policy energy emanating from the executive branch on this topic, as was the case when the Clinton administration failed to overhaul health care policy and when the Obama administration successfully passed the ACA.

Another amazing illustration of the fact that the GOP is by no means repealing and replacing the underlying policy structure of the ACA:

The Obama administration initially requested congressional authorization to make the CSR payments, which are called for in Obamacare, but not explicitly appropriated. The House did not provide it. The administration then paid them anyway, believing that the exchanges would collapse without them. In response, House Republicans sued, arguing that only Congress has the power to appropriate funds. A federal judge agreed that the Obama administration was violating the constitutional separation of powers. The Trump administration has continued making the payments while threatening to withhold them, adding to the uncertainty for insurers operating in the exchanges.

Now Senate Republicans are proposing to explicitly authorize those payments for the first time. That means they are proposing to explicitly authorize and continue the very policy their House colleagues took the previous administration to court for pursuing. It amounts to an expansion of Obamacare, and while it may reduce uncertainty in some markets, it is unlikely to halt premium increases or fully stabilize the exchanges, which were degrading even before Trump threatened to withhold the payments. Moreover, it is an admission that Republicans do not believe they can meaningfully improve on the Obama administration’s implementation of the law.

Emphases mine.  Such a situation also makes it more difficult to reconcile the Senate version with the House version, one suspects (assuming, of course, the Senate version passes, which may not happen).

h/t:  Chris Lawrence for noting the Suderman piece (and the top quote).

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About Steven L. Taylor
Steven L. Taylor is Professor of Political Science and Dean of the College of Arts and Sciences at Troy University. His main areas of expertise include parties, elections, and the institutional design of democracies. His most recent book is the co-authored A Different Democracy: American Government in a 31-Country Perspective. He earned his Ph.D. from the University of Texas and his BA from the University of California, Irvine. He has been blogging since 2003 (originally at the now defunct Poliblog). Follow Steven on Twitter

Comments

  1. Moosebreath says:

    “Rather, the only principles on display appear to be a desire to cut taxes on upper earners.”

    Not just with regard to health care, but with regard to just about all domestic policy.

    Highly-rated. Helpful or Unhelpful: Thumb up 31 Thumb down 0

  2. gVOR08 says:

    I forget which lefty blogger pointed out that bothsidesism isn’t so much finding some example of Dems having done whatever Rs just did massively, it’s more the claim that both sides are dedicated public servants who want what’s best for America but come at it from different perspectives.

    Donald Trump is not where he is because he loves his country. Mitch McConnell does what he does to further the wealth and power of Mitch McConnell. End of story. He delivers tax cuts and deregulation and the beneficiaries shower campaign contributions on him. He is an evil person.

    the only principles on display appear to be a desire to cut taxes on upper earners.

    That’s it.

    It appears that way because it is that way.

    Highly-rated. Helpful or Unhelpful: Thumb up 31 Thumb down 1

  3. Argon says:

    And, quite frankly, if that is what the party is, that is what the party is. But, that isn’t what they have been saying.

    I’ve noticed that phenomena since the Reagan years though post-Gingrich, there seems to be no visible compunction about using the tactic.

    Like or Dislike: Thumb up 14 Thumb down 0

  4. OzarkHillbilly says:

    Why don’t they just shoot me? It would be far cheaper for them and a lot less painful for me.

    Like or Dislike: Thumb up 9 Thumb down 0

  5. rachel says:

    @OzarkHillbilly: They hope you’ll do it yourself and save them the money?

    Like or Dislike: Thumb up 12 Thumb down 0

  6. OzarkHillbilly says:

    @rachel: I have thought about sending them the bullet with a letter expressing what it is to be used for, but I know I would get a visit very soon after and no matter what I say I would still get charged with threatening them..

    Like or Dislike: Thumb up 6 Thumb down 0

  7. Hal_10000 says:

    This is noteworthy because the party has been claiming it has a better approach to health care policy since the Affordable Care Act first was signed into law. They have repeatedly claimed the need to “repeal and replace” and yet, given the opportunity to do so has demonstrated a dearth of actual ideas and solutions

    Are you saying .. they’ve been …. fibbing all this time?

    Like or Dislike: Thumb up 14 Thumb down 0

  8. Daryl's other brother Darryl says:

    7 years and they come up with this abomination.
    So much winning…

    Like or Dislike: Thumb up 12 Thumb down 0

  9. Jen says:

    I certainly don’t want to defend this mess, but isn’t the reason that it doesn’t have any ideas at all in it because they want to use the reconciliation process and its low-vote bar, instead of actually proposing changes to the law that would mean a new bill, and the potential for the filibuster process?

    Also, the reason that there are no new policy ideas in this area, and probably the reason why there is no new bill being introduced, is because there is no way to reform health care in any meaningful way that wouldn’t impact the insurance lobby, the doctors’ lobby, and the pharmaceutical lobby. Real reform–reform that covers more people and gets costs under control–is going to be hard, and financially painful, for the health CARE industry, not just the health INSURANCE industry. Nobody wants to make that move, and we’re headed to real disaster because of it.

    Highly-rated. Helpful or Unhelpful: Thumb up 33 Thumb down 1

  10. @Jen: I think you raise some very real and salient issues.

    Like or Dislike: Thumb up 10 Thumb down 0

  11. Daryl's other brother Darryl says:

    Can someone point out for me the Conservative principles that support this mess?
    This is only about two things:
    Tax cuts for the wealthy
    Undoing anything Obama did
    This bill is cruel. There is really no other description for it.

    Highly-rated. Helpful or Unhelpful: Thumb up 17 Thumb down 0

  12. James Pearce says:

    I’d quibble with Suderman on this:

    Moreover, it is an admission that Republicans do not believe they can meaningfully improve on the Obama administration’s implementation of the law.

    It’s an indication, not an admission.

    An admission would be Republicans saying with their mouths or in writing, “We don’t believe we can improve on Obamacare.”

    Like or Dislike: Thumb up 5 Thumb down 1

  13. Moosebreath says:

    @Daryl’s other brother Darryl:

    “Can someone point out for me the Conservative principles that support this mess?
    This is only about two things:
    Tax cuts for the wealthy
    Undoing anything Obama did”

    Those are the guiding principles of self-described conservatives these days.

    Like or Dislike: Thumb up 11 Thumb down 0

  14. Kylopod says:

    @James Pearce:

    It’s an indication, not an admission.

    An admission would be Republicans saying with their mouths or in writing, “We don’t believe we can improve on Obamacare.”

    That’s an important point, but in defense of Suderman it’s a common rhetorical device to use the term “admission” to suggest a person’s actions reveal their true intentions–as in “The fact you’d say that is an implicit admission you have no answer.” I don’t think Suderman was suggesting the Republicans are being honest about their lack of ideas; far from it.

    Like or Dislike: Thumb up 9 Thumb down 0

  15. john430 says:

    @Jen: Am not a health-economics expert but it seems to me that a “small” measure of cost-control can still go a long way.

    I would impose a sliding scale co-pay on Medicaid recipients. Medicare has it. I wouldn’t care if it was as little as 25 cents per patient visit. It would make Medicaid users put some “skin” into the game. The 2017 estimate of Medicaid patients is 73 million. Truly indigent folks would pay nothing if the plans include income verification while others may pay a dollar or more. Sliding scale–remember?

    Additional thought…higher copays for frivolous Emergency Room visits. Either that or they have a deductible for the next quarter. Abuse of ER facilities (many with no chance of financial recovery) cost hospitals millions.

    According to the American Hospital Association: In 2015, community hospitals have provided more than $35.7 billion in uncompensated care to their patients.

    Like or Dislike: Thumb up 1 Thumb down 11

  16. michael reynolds says:

    1) Greed.
    2) Racist spite.

    That is Trumpcare.

    Like or Dislike: Thumb up 13 Thumb down 0

  17. Jen says:

    @john430: That would do next to nothing to address the cost issue. Additionally, one of the reasons that some Obamacare costs were higher than expected was that many of the newly insured–the Medicaid expansion recipients–were sicker than anticipated because they had delayed care for so long. “Skin in the game” doesn’t work in this situation.

    The cost issue is incredibly complex, and it’s driven in part by “super users,” by excessive testing, by prescription drugs, by redundant or overlapping care, etc. Charging someone a quarter to go and see the doctor isn’t going to fix this situation.

    ER visits are an issue, but it’s not the cost driver that people think it is.

    Highly-rated. Helpful or Unhelpful: Thumb up 19 Thumb down 0

  18. OzarkHillbilly says:

    @Daryl’s other brother Darryl:

    This is only about two things:
    Tax cuts for the wealthy
    Undoing anything Obama did

    Those are the only “conservative” principles in existence.

    Like or Dislike: Thumb up 6 Thumb down 0

  19. al-Ameda says:

    @john430:

    According to the American Hospital Association: In 2015, community hospitals have provided more than $35.7 billion in uncompensated care to their patients.

    This is a part of what Medicaid expansion was intended to cover.

    MA Expansion gave under-served rural area hospitals and clinics a more reliable source of funding to cover the low income populations that they serve. Otherwise these hospitals and clinics close. That has certainly been the case here in California, particularly in the Central Valley, Sierra counties, and low population centers in the north coast areas.

    Like or Dislike: Thumb up 14 Thumb down 0

  20. Moosebreath says:

    The Shrill One hits the nail on the head:

    “Who benefits? It’s all about the tax cuts, almost half of which will go to people with incomes over $1 million, the great bulk to people with incomes over 200K.

    So, is this bill good for you? Yes, if you meet the following criteria:

    1.Your income is more than $200,000 a year
    2.You have a job that comes with good health insurance
    3.You can’t imagine any circumstances under which you lose that job or income
    4.You don’t have any family members or friends who don’t meet those criteria
    5.You have zero empathy for anyone else

    The set of people who can check all these boxes is not a winning political coalition. But Republican leaders believe that their voters are tribal enough, sufficiently walled off from information, that they’ll ignore the attack on their lives and keep voting R – indeed, that as they lose health care, get hit with crushing out-of-pocket bills, see their friends and neighbors face ruin, they’ll blame it on Democrats.

    I wish I were sure that this belief was false.”

    Using the words “Better Care” in the title of this bill reminds me of a line from Yes, Minister, “Put it in the title. It does far less damage than in the body of the legislation.”

    Like or Dislike: Thumb up 14 Thumb down 0

  21. Kylopod says:

    @Moosebreath:

    The set of people who can check all these boxes is not a winning political coalition. But Republican leaders believe that their voters are tribal enough, sufficiently walled off from information, that they’ll ignore the attack on their lives and keep voting R

    I’ve been thinking recently of an anecdote that illustrates the power of partisanship in the health-care debate. Elizabeth Hilsabeck of Texas gave birth to a son with CP, and the managed care provider she and her husband were enrolled in refused to cover the treatment the son needed to learn to walk, on the grounds that it didn’t constitute “rehabilitative” therapy.

    Hilsabeck’s story, which ended with her having to move out of a nice three-story house to live in a trailer due to the crushing expenses needed to take care of her son, is recounted in Jonathan Cohn’s 2008 book Sick: The Untold Story of America’s Health Care Crisis–and the People Who Pay the Price. She became a prominent advocate for what would come to be known as a Patient’s Bill of Rights, which the Texas legislature passed in the 1990s only to have it vetoed by Governor George W. Bush. Later, the legislature tried again, and fearing his veto would be overridden, Bush finally allowed the bill to go through without his signature.

    During one of the 2000 presidential debates, Bush was asked about the version of the Patients Bill of Rights then being debated in Congress, called Dingle-Norwood. Bush stated that as governor he had “brought Republicans and Democrats together…to get a patient’s bill of rights through.” It was a flat-out lie that the media virtually ignored. Instead, the media jumped on Gore for a misstatement where he claimed to have traveled with a particular federal official to a fire, and it turned out he’d traveled with that official during a different incident–an utterly trivial mistake that could easily be attributed to a memory lapse.

    The media did bring up the exchange over the Patients Bill of Rights, however. After Bush repeatedly refused to state where he stood on Dingle-Norwood, Gore finally walked up to him on the stage and spat out, “What about the Dingle-Norwood bill?” The issue, according to most media accounts, was that Gore came off overly aggressive. That was it.

    One person who was actually paying attention to the substance of the debate was Elizabeth Hilsabeck, who, according to Cohn, was absolutely livid when she heard Bush take credit for a policy he had opposed which she had tirelessly pushed for. “Despite this,” Cohn noted, “Elizabeth, a lifelong Republican, voted for Bush anyway.”

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  22. David Anderson says:

    @john430: John, nominal co-pays are already common in Medicaid. There are numerous examples of states using 1115 waivers to impose premiums up to 2% of income for Medicaid expansion.

    Fundamentally Medicaid is the lowest cost insurer once you adjust for risk (babies are expensive, disabled people are expensive, nursing homes are expensive)

    Like or Dislike: Thumb up 6 Thumb down 0

  23. Monala says:

    @john430:

    I would impose a sliding scale co-pay on Medicaid recipients. Medicare has it. I wouldn’t care if it was as little as 25 cents per patient visit. It would make Medicaid users put some “skin” into the game. The 2017 estimate of Medicaid patients is 73 million. Truly indigent folks would pay nothing if the plans include income verification while others may pay a dollar or more. Sliding scale–remember?

    I actually agree with this. There was a year in which my husband and I were both working at jobs that did not offer insurance. We went uninsured, but covered our daughter through the SCHIP program –basically, Medicaid for kids, put in place during the Clinton administration. Because we had incomes above poverty level, we paid a premium. It wasn’t much, about $45 a month, but well within what we could afford. I was happy to pay it for the peace of mind of knowing my daughter’s health care needs were covered.

    Like or Dislike: Thumb up 2 Thumb down 0

  24. Ben Wolf says:

    It doesn’t introduce anything new because the ACA itself was an adaptation of a plan the not-so-nuts Republicans of yore wrote in response to HillaryCare. All today’s Republicans know to do is try and f**k it up.

    Like or Dislike: Thumb up 8 Thumb down 1

  25. Kylopod says:

    @Ben Wolf: I don’t think the Republicans ever really cared about healthcare. The HillaryCare alternative was something they simply proposed as a foil, just to show they believed in reform. After HillaryCare died, they did absolutely nothing to actually push forward a reform bill, not even in the three years they had unified control of government under Bush. At the state level, only blue-state governors like Romney and Schwarzenegger seriously pursued it.

    Like or Dislike: Thumb up 8 Thumb down 0

  26. Guarneri says:

    Resolved. Both parties are beholden to campaign financing interests, and therefore produce a never ending stream of rubbish for legislation. (Despite the pathetic preening here by Democrats).

    Resolved, the only solution is smaller government.

    Glad we can all agree.

    Poorly-rated. Helpful or Unhelpful: Thumb up 0 Thumb down 17

  27. Just 'nutha ig'nint cracker says:

    @Moosebreath:

    The set of people who can check all these boxes is not a winning political coalition. But Republican leaders believe that their voters are tribal enough, sufficiently walled off from information, that they’ll ignore the attack on their lives and keep voting R – indeed, that as they lose health care, get hit with crushing out-of-pocket bills, see their friends and neighbors face ruin, they’ll blame it on Democrats.

    The real problem for people who care about this problem (I’m rapidly moving away from that cohort, btw) is that the Republican leadership is probably correct in their beliefs.

    Like or Dislike: Thumb up 0 Thumb down 0

  28. Just 'nutha ig'nint cracker says:

    @Guarneri: I am breathlessly awaiting your suggestions of what parts of government you wish to reduce in size and what functions of government you wish to eliminate.

    On second thought, I’d probably be wiser to not await these suggestions breathlessly.

    Like or Dislike: Thumb up 3 Thumb down 0

  29. Kylopod says:

    @Guarneri:

    a never ending stream of rubbish

    Kind of like your comments to this site, no?

    Like or Dislike: Thumb up 7 Thumb down 1

  30. Gromitt Gunn says:

    @john430:

    Medicare does not have income-sensitive sliding scale co-pays. It has premium tiers that are income based instead. Fees for services are set on a plan-wide level.

    Tiered premiums have no effect on utilization, since they are charged to all participants independent of utilization.

    Like or Dislike: Thumb up 5 Thumb down 0

  31. Moosebreath says:

    @Guarneri:

    Counter-resolution — the only solution is campaign finance reform.

    Like or Dislike: Thumb up 8 Thumb down 0

  32. Gromitt Gunn says:

    @john430: Additionally, stares are already allowed to impose cost-sharing on specific classes of Medicare recipients for specific services.

    The most vulnerable populations (children, the disabled, people living in insitutions) can not have cost-sharing imposed upon them. And certain services are considered so important that they need to be covered without income-sensitive construction sharing.

    But most elective and/or non-emergency services are subject to cost sharing for people with incomes above the poverty line.

    https://www.medicaid.gov/medicaid/cost-sharing/out-of-pocket-costs/index.html

    Like or Dislike: Thumb up 0 Thumb down 0

  33. Ben Wolf says:

    @Guarneri:

    Resolved. Both parties are beholden to campaign financing interests, and therefore produce a never ending stream of rubbish for legislation.

    Not liberals. They’re much too principled.

    After President Donald Trump’s upset election victory, Democratic insiders who worked on Hillary Clinton’s failed presidential bid weren’t necessarily relegated to the sidelines. Many, in fact, are cashing in as lobbyists — by working to advance Trump’s agenda.
    Lobbying records show that some Democratic fundraisers, who raised record amounts of campaign cash for Clinton, are now retained by top telecom interests to help repeal the strong net neutrality protections established during the Obama administration.

    Others are working on behalf of for-profit prisons on detention issues, while others still are paid to help corporate interests pushing alongside Trump to weaken financial regulations. At least one prominent Clinton backer is working for a health insurance company on a provision that was included in the House Republican bill to gut the Affordable Care Act.

    While Republican lobbyists are more in demand, liberal lobbyists are doing brisk business that has them reaching out to fellow Democrats to endorse — or at least tamp down vocal opposition to — Trump agenda items.

    https://theintercept.com/2017/06/23/democratic-lobbyists-donald-trump-mottur-podesta-comcast-prudential/

    Like or Dislike: Thumb up 5 Thumb down 2

  34. OzarkHillbilly says:

    @Monala:

    We went uninsured, but covered our daughter through the SCHIP program

    Lucky for you, your daughter was born in a time when Republicans still had a soul. Sad to say, they don’t anymore.

    Like or Dislike: Thumb up 3 Thumb down 0

  35. MBunge says:

    Off topic, but there’s apparently some rumbling Anthony Kennedy could announce his retirement as Monday. If true, is there anyone who doesn’t now understand that THIS is when they should have forced Republicans to use the “nuclear option?”

    Mike

    Like or Dislike: Thumb up 0 Thumb down 7

  36. Scott F. says:

    @MBunge:

    I don’t know that this is off-topic.

    If you recognize that what is happening with the BCRA is conclusive proof that McConnell and Company can dump all over the institutional norms of the Senate and it will cost them nothing in public standing (particularly with their zombie base), then how do you figure there was a better time to fight for SCOTUS?

    There is no truth, there are no rules, there are no norms… Welcome to Trump’s America.

    Like or Dislike: Thumb up 12 Thumb down 0

  37. Moosebreath says:

    @MBunge:

    “If true, is there anyone who doesn’t now understand that THIS is when they should have forced Republicans to use the “nuclear option?””

    The effect of forcing the Republicans to use the nuclear option in the second half of 2017 instead of the first half would be different because…?

    Please include in your response talking points which respond to the so-called liberal media saying that if Gorsuch was not unacceptable to Democrats, why should nominee X be?

    Like or Dislike: Thumb up 10 Thumb down 0

  38. Guarneri says:

    @Ben Wolf:

    Don’t tell the lunatics here. They are perpetually in denial.

    Like or Dislike: Thumb up 0 Thumb down 4

  39. DrDaveT says:

    @Ben Wolf: Let me get this straight — you’re pointing out that Democrats who aren’t actually office-holders, or even candidates, are working behind the scenes to not actually accomplish any legislation for Trump?

    What, exactly, does that have to do with which party actually helps people with the laws they actually pass?

    Like or Dislike: Thumb up 2 Thumb down 1

  40. Ben Wolf says:

    @DrDaveT:

    Let me get this straight — you’re pointing out that Democrats who aren’t actually office-holders, or even candidates, are working behind the scenes to not actually accomplish any legislation for Trump?

    What, exactly, does that have to do with which party actually helps people with the laws they actually pass?

    That's a debate tactic called "moving the goalposts" in which an argument is deflected by demanding the opponent satisfy more and more premises after the initial argument is satisfied.

    So the initial premise "Democrats are influenced by money" is satisfied by the Intercept story revealing Democrats are going to work helping Donald Trump because they can make money. You then argue that "Democrats" must be narrowly defined as "office-holders and candidates" and that others must then demonstrate how those office-holders and candidates are influenced by money.

    It's an indication you aren't hear for a good-faith discussion.

    Like or Dislike: Thumb up 0 Thumb down 3

  41. Bob@Younsgtown says:

    Still on the topic of the “Better Care” draft – Perhaps some of our more knowledgeable commentators can answer two questions:

    1) Does the Better Care draft retain the ACA’s 80 % medical loss ratio requirement for insurance carriers?
    2) Does the Better Care draft retain the ACA’s the requirement that Congress and their staff purchase their personal healthcare insurance from the public exchange?

    (by way of explanation the medical loss ratio above is that provision of ACA that insurers must spend 80% of their premium receipts on actual payout to claimants)

    Like or Dislike: Thumb up 1 Thumb down 0

  42. wr says:

    @Bob@Younsgtown: “1) Does the Better Care draft retain the ACA’s 80 % medical loss ratio requirement for insurance carriers?”

    I believe I’ve read that it takes it down to about 53%.

    Like or Dislike: Thumb up 0 Thumb down 0

  43. Bob@Youngstown says:

    @wr:

    I believe I’ve read that it (the Senate’s Draft) takes it (medical loss ratio) down to about 53%.

    OMG !!! If accurate that would be a real gift to the insurance industry leaving the insured to be gouged.

    Like or Dislike: Thumb up 0 Thumb down 0

  44. Catchling says:

    @Bob@Youngstown: And 53% is less than the lowest percentage for any company pre-ACA. Thus almost meaningless as a “limit” — “You are hereby prohibited from dong anything worse than you were planning to anyway.”

    Like or Dislike: Thumb up 0 Thumb down 0

  45. Tyrell says:

    @Daryl’s other brother Darryl: I have not had time to properly analyze, study, research, translate, and interpolate this latest plan. I hear and see a lot of hysterics, hype, sensationalism, and theatrics on some of the news media in reaction.
    I will get back with my findings in due time.
    Meanwhile the Obama Care continues to collapse as another insurance company has withdrawn.
    I have presented some of my ideas before, which could lower health costs, expand coverage, and give people more options.

    Like or Dislike: Thumb up 0 Thumb down 0