House Republicans Making Yet Another Push To Repeal And Replace Obamacare
House Republicans are making yet another push to repeal and replace the Affordable Care Act, but they once again may not have the votes.
House Republicans are making yet another push to pass their bill to repeal and replace the Affordable Care Act, but they are once again facing opposition from within their own caucus that threatens to derail the effort for the third time in a month:
Republican efforts to overhaul the nation’s health-care system collided Tuesday with fierce resistance about how it would affect people with preexisting medical conditions, casting the proposal’s future into deeper uncertainty as GOP leaders scrambled to try to salvage it.
On Capitol Hill, influential Rep. Fred Upton (R-Mich.) came out against the plan, dealing a major blow to proponents trying to secure enough votes to pass it in the House. Across the country, late-night host Jimmy Kimmel’s emotional story about his newborn son’s heart condition reverberated on television and the Internet. And former president Barack Obama, who signed the bill Republicans are trying to dismantle, took to Twitter to defend it.
All three voiced concerns about losing a core protection in the Affordable Care Act for people with preexisting conditions, as is possible under the latest GOP plan. Such growing worries threatened to derail the revamped attempt to revise key parts of the ACA — or at least send Republicans back to the drawing board.
“I do think each minute that has passed, each hour and each day, the ‘no’ members are becoming more locked in ‘no,’ and we may be losing members,” said Rep. Chris Collins (R-N.Y.), who favors going back to the original version of the American Health Care Act that was scrapped by GOP leaders earlier this year.
Republicans left their weekly conference meeting Tuesday with no health-care vote on the schedule. The House is slated to recess Thursday until May 16.
In an interview with WHTC radio in Holland, Mich., Upton, a former chairman and current member of the House Energy and Commerce Committee, said he opposes the House GOP plan because it “torpedoes” safeguards for people with preexisting conditions.
“I told the leadership I cannot support the bill with this provision in it,” Upton said. “I don’t know how it all will play out, but I know there are a good number of us that have raised real red flags.”
A Washington Post analysis shows 21 House Republicans either opposed to or leaning against the bill, and 22 more either undecided or unclear in their positions. If no Democrats support the bill, the Republicans can lose no more than 22 GOP votes to pass it in the House.
Upton’s comments came a day after Rep. Billy Long (R-Mo.), a longtime opponent of the ACA, voiced similar concerns as he came out against the latest plan. On Tuesday, Long said the preexisting-condition provision was the sole reason for his opposition.
“They take that out, put the vote on the floor that they pulled, and I’m with them,” Long said, referring to the first version of the bill, which House GOP leaders withdrew in March after it was clear that it lacked the support to pass the chamber.
After the failure, Republicans renegotiated and opted to add an amendment to the bill that would enable insurers to deny coverage or charge more to people with preexisting conditions if their states opted out of provisions in the ACA barring such decisions. The states would have to set up “high-risk pools” to absorb some of the costs of caring for those people.
The idea was to find a middle ground that would attract conservative Republicans who want to do away with as many ACA regulations as possible and centrist Republicans who worry about stripping vulnerable populations of the coverage they receive under the ACA.
That balance has been very hard to reach. And external pressure has made it no easier.
President Trump, who has shown an eagerness to swiftly pass a health-care bill, continued pressing congressional Republicans to act. On Tuesday, Vice President Pence traveled to Capitol Hill again to coax legislators to support the bill. Trump called lawmakers from the White House.
“How’s health care coming, folks? How’s it doing? All right. We’re moving along? All right. I think it’s time now, right? Right?” he said after name-checking some lawmakers in attendance as he presented the U.S. Air Force Academy football team with the Commander-in-Chief’s Trophy at the White House.
Trump has also added confusion to the debate, saying in an interview that aired Sunday on CBS’s “Face the Nation” that the health-care plan would “beautifully” protect those with preexisting conditions.
House Speaker Paul D. Ryan (R-Wis.) appeared keen to avoid signs of discord Tuesday, telling reporters that Trump has been “nothing but helpful” on health care. He and his top lieutenants also tried to defend the GOP plan against criticism that it would harm Americans with preexisting conditions.
“Our bill protects people with preexisting conditions, and it actually provides multiple layers of protection for people with preexisting conditions in ways that Obamacare doesn’t do,” House Majority Whip Steve Scalise (R-La.) told reporters.
Scalise’s defense was that current law offers such protections and any states opting out “actually have to lay out how they are going to protect people with preexisting conditions.”
Rep. Paul A. Gosar (R-Ariz.), a member of the far-right House Freedom Caucus who did not support the first GOP proposal but does back the new one, said he was hearing that a new amendment would add money for the high-risk pools — though he didn’t know how they would be paid for. Collins said he heard something similar, but he was pessimistic that the differences could be ironed out.
All of this comes at the same time that a new poll shows that a majority of Americans oppose the changes that the Republican bill would make to the Affordable Care Act’s provisions regarding guaranteed coverage for pre-existing conditions. In the poll, 50% of the respondents either somewhat or strongly oppose the Republicans oppose the plan’s proposal that would allow states to opt-out of the pre-existing conditions mandate in exchange for setting up a pool of funds for those who would be impacted by the change while only 38% support it. On the broader question of whether the PPACA as a whole should be repealed and replaced, the public is a bit more ambivalent with 42% saying that the approve of the change while 37% disapprove and 20% of respondents saying that they either “Don’t Know” or have no opinion. In another question, 58% of respondents say that Congress should wait until the new bill is scored by the Congressional Budget Office while only 16% said that Congress should go ahead with a vote prior to getting a CBO score. This last bit is significant because it’s clear that the CBO will not be able to score the bill before the House is scheduled to recess on Thursday until May 16th, a period during which many members of Congress will be back in their districts and hearing directly from voters at town halls and other venues, many of which have proven to be quite raucous. This is one reason why leadership appears to be pushing for a vote prior to a recess, because it’s likely that many of the Members of Congress sitting on the fence right now would be likely to vote “No” after more than a week of face-to-face meetings with constituents opposed to the GOP effort to do away with things such as the pre-existing condition coverage mandate.
As things stand right now, the opponents of this latest effort to repeal and replace Obamacare look as though they’ll win again. Different media outlets have slightly different numbers, but there seem to be at least 20 to 21 Republicans already opposed to the bill with another group of somewhere between 20 and 25 members still either on the fence or whose position has not been made public. Since no Democrats are going to vote in favor of the bill, this means that all it would take is 22 Republicans to oppose the bill for it to fail. Looking at the numbers, it seems likely that failure is the most outcome for several reasons. First of all, as the polling indicates, Americans are opposed to one of the central provisions of the new bill and that number is only likely to increase as the details of the proposal to become better known to the public. As I said, this is why the leadership is pushing for a vote prior to the recess that starts tomorrow, because the likelihood is that members who are on the fence will be pushed into the “No” camp once they are exposed to constituents who are strongly opposed to the bill. Second, the fact that there is no CBO score and that the text of the revised bill hasn’t even been made available to the public also leaves legislators who may be on the fence reason to be concerned about backlash if they vote for a bill like this sight unseen, which is essentially what leadership is asking them to do. Finally, as I’ve noted before there is quite simply no chance that this current bill will pass the Senate. That has been made clear from comments not only from Senate Democrats but also several Republicans who object to everything from the way it treats pre-existing conditions to the impact it will have on states that signed on for the PPACA’s expanded Medicaid coverage. Given this, it’s unclear why wavering House Republicans would put their political futures on the line for a bill that has absolutely no chance of becoming law.
There’s likely to be much drama over the next 24 to 36 hours on Capitol Hill, so stay tuned. My guess, however, is that this effort to repeal and replace Obamacare will fail just as badly as previous efforts have.
My question is, Why? Why does Ryan keep coming back to this? Is he afraid of Trump? The Koch’s?
@MarkedMan: Excellent question. Who is lobbying to repeal O’care?
Not that it will do a lot of good, I informed my congressman that if he votes on this “bill” before CBO scores it, I would consider that to be a dereliction of his responsibility to be informed as to the consequences of adoption.
IMO he can vote either way (although I’d clearly urge him to vote in the negative) but to dismiss CBO’s scoring is blatantly irresponsible.
Two trains of thought on this:
One….I would really like to see some leadership from Democrats and have them come forward with smart fixes to Obamacare which, contra the propaganda, is working well but could indeed stand some improvement.
One problem is that Republican leadership on the Hill is ideologically bent. After spending 8 years slamming Obamacare they can’t be seen by the base as wanting to keep it.
Another problem is that the President, who desperately wants any kind of win, and could care less about ideology he can’t even understand, isn’t smart enough to have a serious policy discussion with.
Two…
Joe Walsh (former R-Ill.)
It’s pretty clear, both from this comment and from others made by Republicans over the last few days, that they don’t even really understand how insurance works.
So there is really no wonder why their health insurance plan is a failure.
@MarkedMan:
“Why does Ryan keep coming back to this? Is he afraid of Trump? The Koch’s?”
The latter. Remember this is not a health care bill. It is a tax cut for the wealthy, offset (in part) by reducing the amount the Federal government pays for health care.
OT: Fyre Festival Fiasco Part 6:
Bahamas Don’t Want You No Mo’ Baby (Isn’t there a R&B song with that title somewhere? If not, there should be.)
Next Legal Shoe Drops (Clang!)
ah the joys of schadenfreude…
@grumpy realist:
My freude is over-schadened…
@Daryl’s other brother Darryl: Actually go take a look at how Walsh (“political has-been trolling for attention” for 50 dollars, Alex) has been getting slammed on Twitter. That “deadbeat” reputation is hanging around his neck like a rotting polecat.
Related, but on my mind:
It seems to me that the philosophical mantra being pushed (besides Obama = evil bad) are two things:
1) American’s desire to have freedom of choice in what they (individually) decide to include in their personal healthcare insurance coverage. For example, “I don’t need or want maternity care in my policy, therefore as a American I should not have to pay for something I don’t want”. Beside the lack of understanding about how broad-scale insurance works and marketed, I can’t help but wonder if anyone has determined what the specific reduction in premium would be to delete maternity care. My suspicion is that the cost to produce an individualized policy (with coverage carve-outs) would be greater than a generalized policy.
2) Myth: Multiple providers will reduce the cost of premiums. The profit in healthcare premiums is so thin (suggested to be 1-3% of the gross premiums collected) that the model of ‘more competition is better for the consumer’ just doesn’t work. I’ve tried to compare policy premiums (same zipcode, same coverage, etc) between insurance providers and there just does not seem to be an appreciable difference between providers. I just don’t see the argument that multiple insurance providers (offering identical products) is a financial advantage to the consumer. It may be a psychological pap, not not a financial one.
@MarkedMan: It could have something to do with the “promises” that Republican congressmen have been making for the past eight years. If they don’t actually repeal anything, it’s a bit embarrassing. Luckily for them, most of the American public has the concentration of a goldfish.
Three points;
(1) Wow, some of these people do not bother to mask their contempt and lack of empathy..
(2) ? Does Joe know that in the (non-public) private insurance markets we are always paying for somebody else’s health care? That is exactly what insurance pools are all about. My premium rates and your rates are annually adjusted for many, many factors and the fact is people who extensively utilize healthcare services are, and will continue to be, subsidized by people who do not utilize health care services.
(3) Joe might be interested to know that if say, in a fit of rage, Joe had a heart attack, the combined cost of his emergency care, testing, surgery, and outpatient care would greatly exceed the amount that he pays for his health insurance policy, and yes, other policy holders would be paying for Joe’s health care.
@al-Ameda:
@grumpy realist:
It’s equally important to remember that Joe Walsh is a dead-beat dad. He’s a guy that doesn’t even want to support his own kids. So that’s the kind of person we are dealing with here.
@al-Ameda: (3) Joe might be interested to know that if say, in a fit of rage, Joe had a heart attack, the combined cost of his emergency care, testing, surgery, and outpatient care would greatly exceed the amount that he pays for his health insurance policy, and yes, other policy holders would be paying for Joe’s health care.
If there is karma, Joe will have a heart attack and die miserably alone, and whatever financial resources he has will be left intact. Then his ex-wife can sue his estate for the back child support this POS owes.
Republicans have spent so much time ranting about Obamacare that they have no choice but to try to repeal it.
However, those (few) Republicans who genuinely want to keep people covered while avoiding an alternative that resembles single-payer don’t have a viable plan for doing that unless it resembles…Obamacare.
The most honest conservatives will tell you that they just don’t care whether some people suffer or die for lack of coverage. The rest of them have no grasp of healthcare economics and spew ideas that are simply unworkable, irrespective of political ideology.
Thomas Massie (R-KY)
@Bob@Younsgtown: The deep desire to not have maternity care in their policies comes mostly from old people, who would probably be surprised to learn that their policies are structured and priced assuming that very, very few of them will actually be making use of that maternity care coverage.
@Bob@Younsgtown: I also have called and faxed my Congressman (Lamar Smith, not that it would do any good). I tried a different angle. I focused on the tax cut part saying we can’t afford the tax cuts and increase the debt. In all my 60 plus years have I communicated with my elected official as I have in the last year. Now I got their phone numbers (DC and local) in my contacts. I have found Faxzero.com to be an easy way to fax letters to them as they have the congressional fax numbers preloaded.
Still, I wonder what good it does.
@Gustopher:
I’m convinced that the vast majority of people have no idea how insurance works – pooling, risk adjusting – none of it.
Not surprising I suppose, in light of the fact that many people think they’re making a cogent point when they say, “keep government out of my Medicare.”
I still don’t understand why the GOP is pushing this. Even their own voters don’t rate healthcare repeal that high on the list of things to do.
Even if this bill makes it through the House, it is dead in the Senate. So in the end, all you did is attached your name to very a unpopular bill, one year before the mid-terms.
@al-Ameda:
What they’re really saying is that it isn’t possible for you to help that other guy without hurting me, so keep things as they are.
It’s the I’ve Got Mine mentality in action. Modern conservatism embraces selfishness as a virtue.
Never interrupt your enemy when he’s shooting himself in the face
@gVOR08:
The insurance companies, I reckon. They have not seen enough money come in from the individual mandate to offset the (totally expected) losses, and state regulators usually have authority to cap premium increases. Some hospitals are still lobbying on Medicaid/Medicare reimbursement.
Why they can’t read the writing on the wall and start to reform the system under the current framework is beyond me.
@al-Ameda: The subsidization of other people’s costs is an important factor in the whole discussion. Over the years, i have had times when I couldn’t afford healthcare insurance premiums–such as the period in the late 90s to the early new milennium when I was earning about $13,000/year doing part-time and substitute teaching. Even though I was a relatively heavy user of healthcare as I suffered from chronic bronchial asthma, my year-on-year medical costs were often less than premiums for coverage. Years that I needed to be retested for progress evaluation were more costly, and as drug therapy increased in its sophistication, drug costs went up, but most years, even I would have been spending more on premiums than I received in benefits.
Now if I had needed surgery or gotten cancer…
@Daryl’s other brother Darryl:
.
Cleek’s Law says it is more productive they keep out of sight.
@SenyorDave:
I think you’re assuming he has a heart to attack.
@Jen:
Although this would seem likely, there hasn’t been much evidence to that effect. Obamacare didn’t cut into the private market as much as was feared, and millions more private insurance policies were issued to people who otherwise wouldn’t be a revenue source. So my impression (and there is no evidence here, just an impression) is that they are not the most Importent players here. I do know that in the original implementation they spent most of their lobbying effort on the rule writing phase, which makes a huge difference to their bottom line.
@MarkedMan: Anthem has been pretty active on this front:
http://fortune.com/2017/03/10/anthem-gop-healthcare-plan-obamacare-repeal/
There has also been a lot of back-and-forth about withdrawing from the exchanges, using a carrot/stick lobbying approach.
Insurance companies love Obamacare…look at the before and after stock prices for the big 6 HMOs…collectively up over 300% since 2011 when Obamacare was passed.
The DJIA by contrast has gone up 200% in that time frame….so they are killing the market.
Insurance companies are guaranteed now a huge new source of users by virtue of the mandate.
@MarkedMan: …I will add, this is one reason why I never thought repeal was going to be successful. There are just too many changes that have already been woven into too many different sectors of the healthcare system for there to ever have been a clean break. Even rolling back to pre-Obamacare would represent a huge loss, because of all of the money that has been invested in getting systems in place, etc.
And, now that the markets seem to be stabilizing a bit (surprise, surprise!), it’s even less likely.
Meanwhile, The Hill is reporting that the Tuesday Morning Group is thinking of ousting MacArthur for working with the Freedom Caucus on the most recent iteration of the bill. Republicans are going at each other over this.
@the Q: They don’t love all of it. Even though they are posting profits, we still see this:
Emphasis added. That language sounds very familiar, doesn’t it?
@Jen:
Because the insurers know that the subsidies that are needed to support the program are too fragile to be relied upon over the long run.
ACA was an improvement over the old non-system, but it included a number of failings that ultimately make it unsustainable. It isn’t so robust that it can’t be killed off with just a bit of effort.
Obamacare didn’t go nearly far enough to make itself self-perpetuating. Trying to craft the system while simultaneously preserving most of the employer-based system was a mistake.
@Pch101:
Yes–I know, and I agree. I wasn’t really asking a question–it’s an incredibly complex problem (not the least of which is how much of the US economy is tied to healthcare related spending, and how many people the system employs). I’d like for the solving of the problems to begin at some point, and repealing Obamacare isn’t going to fix anything. It never was going to, of course.
@Jen:
Insurers want to make money. If the revenue stream is not sustainable, then they will want the opportunity to adjust and deal with it.
Having the GOP in charge puts the program in jeopardy, so insurers need to prepare accordingly. Reform ain’t gonna happen, so there is no point in pretending that such a thing is possible.
@gVOR08:
Repeal? Ideological purists, haters and billionaires. Seriously. Everyone else from insurance companies to the general public want various tweaks to keep the good and minimize what they see as the bad. Only those who can’t stand the thought of socialized anything, can’t let Obama/ Democrats/ Liberals / Those People have a victory even at their own expense, or want extra cash they don’t need at the cost of American lives and health to line their pockets want it completely gone.
@al-Ameda:
But that’s the gig you sign up for. Premiums in return for (hopefully) the rare event you have catastrophic loss.
you may have heard of it. Its called insurance.
@Guarneri:
Apparently the leaders of your cult have not heard of it…so there’s no way for them to understand how it works…much less reform it.
@Pch101: Again, we’re on the same side here, I’m pretty sure. I’ve worked on healthcare policy at different points in my career for the last 25 or so years–I get it.
@Jen: great to have someone with your background in the discussion. Any insight into what repeal would mean to the other parts of OCare? Things like nommhospitals having to pay for HAI etc?
@MarkedMan: Ha, well–key point in my post was “at different points in my career”–I’m by no means an expert, but have worked on the legislative side and the lobbying side. It’s been a couple of years since I was actively involved, but I am asked to do some issues-based writing occasionally so I am required to keep up.
That said, and assuming you are referring to HACRP, nobody likes to see their payments reduced, but this hasn’t been a key sticking point for the clients I’ve worked with, so it’s not my area of expertise. If you want to talk about capitation rates, doctor reimbursement, implementation of electronic records, etc., I’d probably be a little bit more useful. 🙂
OT, but remember when we were talking about Obama’s 400k speech and I defended him because I didn’t think he’d sold anything but his time, and we should give it a rest? The Obamas just donated 5 times that much to a jobs program. Think maybe that’s where the speechifying money will go? To charity? And if it goes to charity, don’t you want it deducted from big Wall Street bank accounts?
@MarkedMan:
They never were. Historically, the most fervent opponents of expanding health care coverage in this country came not from the insurance companies but from the medical lobby. They played a key role in the downfall of FDR’s two aborted attempts at health-care reform, Truman’s push for universal health care in the ’40s, Nixon’s in the ’70s, and Clinton’s in the ’90s. They also strongly campaigned against the creation of Medicare and Medicaid.
Indeed, it’s worth noting that the AMA actually opposed private insurance when it first emerged in the ’30s. They eventually made peace with it when they realized it was the only way to stop the US from developing a national health care system as was happening in many other countries at the time. But if they’d had their way, patients would still be paying medical expenses out of pocket.
@Jen:
So – what’s a capitation rate?
And, FWIW, I know hospitals and other providers have been scrambling for years to implement usable EMR, but I haven’t seen much benefit yet. If for no other reason than the bizarre way we are implementing them in the US. Ten years ago, when my brother lived in the Netherlands, all of his Dutch friends had EMR’s that dated back through their whole lives (or the advent of the EMR system), with every entry kept regardless of where it was done. In the US, every hospital, X-Ray clinic, doctor and dentist implements their own electronic record, usually incompatible with everyone else. I’ve personally lived in three different countries and 15 or so cities and towns, so my “medical records” are just a mishmash. It mostly consists of what I remember to tell my doctor. Have you seen any tangible benefit other than the ecological one of fewer dead trees?
@Jen:
So – what’s a capitation rate?
And, FWIW, I know hospitals and other providers have been scrambling for years to implement usable EMR, but I haven’t seen much benefit yet. If for no other reason than the bizarre way we are implementing them in the US. Ten years ago, when my brother lived in the Netherlands, all of his Dutch friends had EMR’s that dated back through their whole lives (or the advent of the EMR system), with every entry kept regardless of where it was done. In the US, every hospital, X-Ray clinic, doctor and dentist implements their own electronic record, usually incompatible with everyone else. I’ve personally lived in three different countries and 15 or so cities and towns, so my “medical records” are just a mishmash. It mostly consists of what I remember to tell my doctor. Have you seen any tangible benefit other than the ecological one of fewer dead trees?
@MarkedMan:
In short, no–it’s been a very expensive experiment. Getting all of the different systems–even within a hospital–to interact correctly has been extremely difficult. That said, there is progress being made on delivery and patient interaction. With updated programs and systems, patients are able to do things like schedule appointments and get secure messages from their doctors, which does free up some administrative time. Everyone still is hoping that the benefits of EMRs will eventually work out…
On capitation rates–it’s a managed care method to get a handle on costs, and it’s been around (and controversial) for a while. Doctors don’t like it much because it sets a flat payment fee for the number of patients they see per month. So, if a doc sees 50 patients in a month, there’s a capped fee–even if 45 of those patients took much longer to care for/needed more time or services in office, etc. If you have a standard fee for service payment, there’s an (alleged) incentive to provide more care to generate more revenue. A capitation rate is supposed to address that.
@gVOR08: @Jen: @MarkedMan: @KM: @Kylopod:
I see POLITICO has an article up saying that the whole health care industry, insurance, doctors, hospitals, patient advocacy groups are against passing the current bill, for O’care.
I’m still puzzled as to why the Rs are so hot to do this. Fred Thompson said, “Russians don’t take a dump son, without a plan.” And Republicans don’t cast a vote without a buyer.
I’m left with @Moosebreath:’s theory. Ryan desperately wants to push big tax cuts and needs some pretense of savings in health care to get it.
Ryan is pushing the healthcare repeal because of the funding sources in the ACA. The tax cut isn’t complete without eradicating those funding sources (taxes) on rich people that make the transfers to Medicaid and the subsidies possible.
Ryan doesn’t want to use taxpayer dollars to keep the “wrong” people alive.
Trump is a pathological liar who makes promises that he can’t keep because he is completely indifferent to the truth.
At this point, the Republican party is a criminal gang, not a political party.
@Guarneri:
As I mentioned above, quite clearly Joe Walsh does not know how private insurance works. Non-users of health care services to varying degrees subsidize intensive users of health care services. When you or I buy health insurance (or have our employers provide a plan offering that we take on) we may or may not be subsidized by other policy holders in that pool, it depends on utilization of health and medical services. It’s how insurance pools work.
You’ve heard about insurance pools and risk assessment, right?
@gVOR08: Thanks for sharing that article–it is about as thorough a piece that I’ve seen that explains some of the inside baseball that is necessary for getting a piece of legislation passed:
Emphasis added to the part that is key right now. Everyone got something, so any changes or reforms threaten somebody’s piece of the pie.
And yes, it’s all about the tax cuts. If this goes down–and that seems like a given–tax reform is in trouble too.
@Jen: While the rational world has been pelting them with calls against repeal, they’re also getting calls along the lines of Limbaugh’s screed on, ‘why would anyone vote Republican, we won, but we don’t get anything.’ They’re terrified they’ll be primaried and lose their cushy jobs if they don’t pass a repeal bill. They know the bill is a POS that will cause them grief if it goes into effect and they’re hoping the Senate will save them.
My “Representative”, Brad Wenstrup, is a gutless ignorant hillbilly. Apparently he’s typical.
@al-Ameda:
Guarneri only knows what Zero Hedge tells him. Which is to say that he knows less than nothing, for much of what he “knows” to be true is false.
It passed. Just to reiterate something I’ve been saying for years – in the end, Republicans in Congress do what they are told. Negotiations, moderates, “but my Republican Representative is one of the good ones”, none of that means anything. In the end, they do what they are told. Which is why responsible voters should not vote for any Republican, in any position, at any level.