If Republicans are managing to overhaul the nation’s tax code, why in the world can’t they repeal and replace Obamacare — a task that was supposed to be easier?

In the weeks after the Senate famously failed to pass its health-care bill in July, several leading GOP lawmakers said they viewed taxes as an even steeper climb. Senate Finance Committee Chairman Orrin Hatch (R-Utah) told CNBC that overhauling the tax system is are even more divisive and complex than revamping the health-care one. Sen. Bob Corker (R-Tenn.) also told the network that taxes are trickier because they involve so many special interests (in fairness to Corker, he was the only Senate Republican to oppose the tax plan over concerns about it would explode the deficit).

“Personally, I think tax reform is harder than health care,” Corker said. “My whole August was meeting with people who were saying, ‘Corker, I’m all for pro-growth tax reform, but there is this one thing we don’t want you to touch.’ ”

Yet after the Senate passed its version in the wee hours last Friday, Republicans find themselves speeding toward a final, sweeping tax bill while their first priority of the year — repealing and replacing the Affordable Care Act — is stuck in an awkward limbo state. (We should insert an important caveat here that Republicans may not be finished with their efforts to upend the ACA. There are lots of behind-the-scenes discussions underway about how they could return to the task after finishing taxes.)

Radio reporter Jamie Dupree noted similarities between the health-care and tax efforts:

But the similarities only extend so far, because Republicans appear to be winning with their taxes gambit. From Rep. Seth Moulton (D-Mass.):

Rep. Bill Pascrell (D-N.J.):

Top Senate Democrat Chuck Schumer (D-N.Y.):

So why, exactly, is the GOP getting its No. 2 legislative priority done before its No. 1 legislative priority? Let's take a look at a few of the possible reasons:

1. Taxes are a comfortable language for Republicans. Health care isn’t.

Republicans engaging with health care is kind of like The Health 202 trying to discuss sports — the woeful ignorance would be instantly apparent. Okay, so maybe that comparison is a tiny bit unfair to GOP lawmakers, but the point remains that not enough of them have invested in understanding the complicated system governing how Americans get their coverage.

Consider this: The GOP-led House voted more than 70 times to repeal parts of the Affordable Care Act while President Barack Obama was in office. But Republicans never did the hard work to write a replacement bill, beyond a rough blueprint floated by House Speaker Paul Ryan (R-Wis.) last year.

There’s also a relatively thin Republican health-care bench. Most of the top policy staffers from when the ACA was being debated quickly fled for better-paying gigs off Capitol Hill. Back when I worked for Politico, I wrote that about three years after the ACA was enacted, a slew of GOP staffers on key health committees made their exits.

Ultimately, if you’re a Republican lawmaker, you get most jazzed about cutting taxes and diminishing the role of a government you feel is too big — and perhaps not as excited about ensuring everyone gets health coverage, a task that is extremely expensive and seems to include more government involvement.

“Unlike on health care, there has long been a general consensus within the GOP on what should replace the current system: a simpler tax code that will allow many people to keep more of what they earn,” David Schnittger, deputy chief of staff for former House speaker John A. Boehner, told me.

2. The health-care implosion lit a fire in GOP bellies to succeed on taxes.

It was humiliating for Senate GOP leaders, to say the least, to fail in passing even a slimmed-down ACA repeal bill. They’d already suffered through a summer of blistering outcries against their health-care measure, whose writing was guided by Senate Majority Leader Mitch McConnell (R-Ky.) in an effort to shape policies that both conservatives and moderates could back.

“The failure on health care led to a clear sense of urgency to help the tax system,” Doug Holtz-Eakin, former director of the Congressional Budget Office under President George W. Bush, told me.

Schnittger credits all the floundering on health care for escalating a tax overhaul into a “full-fledged do-or-die mission.”

“The impasse on health care actually helped by creating a political imperative,” he said.

3. Republicans were haunted by more specific promises on health care than on taxes.

Republicans largely ran for office vowing to replace a law that expanded coverage to around 20 million Americans. But to replace it, they had to figure out how to keep those people covered or risk huge public pushback. We know how that turned out — both the House and Senate health-care bills suffered from terrible approval ratings because they were estimated to push the uninsured rate back up to pre-ACA levels.

In addition, the specific promises to root out the law also prompted trouble with conservatives, who balked when they discovered the various GOP bills left big parts of the ACA in place.

“That specificity really hurt them,” Holtz-Eakin said. “In contrast, tax reform is the nicest-sounding thing in the world — it’s better than puppies, kittens and sunshine.”

4. Industry fought the health-care effort tooth and nail, but not so much the tax overhaul.

The tax bill certainly prompted opposition from some industry stakeholders, as my colleague Tory Newmyer has reported over at The Finance 202. For example, the National Association of Realtors said it couldn’t support such sweeping changes to the individual and corporate tax code, and the U.S. Chamber of Commerce initially offered lukewarm support for the process though it eventually urged lawmakers to support the measure.

But there was nowhere near the level of outside opposition to the tax overhaul as to all the different versions of health-care proposals. Doctors, hospitals, patient advocates and insurers alike were vehemently opposed to all the GOP bills because they would have caused far fewer people to have coverage and therefore affordable access to care.

“The business community genuinely held their fire, recognized this was their chance to get something done and didn’t pick it apart on the specifics,” Holtz-Eakin said. “With health care, the stakeholders were ripping it apart at every stage.”


AHH: Here’s why President Trump is both right and wrong when he says Obamacare premiums are rising, per the New York Times’s analysis of data from the McKinsey Center for U.S. Health System Reform.

Strictly speaking, it's definitely true that premiums are up -- way up, in many cases: Premiums for bronze plans, which generally have high deductibles but low premiums, increased a median of 18 percent from 2017 to 2018. But insurers have also dramatically hiked premiums for their silver-level and gold-level plans since 2014. 

But many lower-income Americans are paying less because government subsidies have also gone up: People who qualify for federal premium subsidies are getting even larger subsidies than last year because of how they're calculated (based on the price of the second lowest-cost silver plan.) That basically means that for qualifying customers, the cost of silver plans may have actually dropped since last year in a majority of counties nationwide.

Who’s to blame for making things more expensive? More like what is to blame and that's the failure of ACA marketplaces to attract enough healthy customers to keep risk pools diverse and tamp down premiums so that insurers aren't bleeding money. And also the Trump administration, to some extent. Insurers who have raised their silver-plan premiums this year partially credited the administration’s move to end extra cost-sharing subsidy payments for discounts they're still required to provide.

OOF: How can you best persuade parents in the United States to vaccinate their kids, if they're hesitant? Maybe not the way you'd think. Most public-health messages rely on facts and science to explain how immunization not only protects children but also shields other vulnerable people from infectious disease. But research shows that information campaigns emphasizing fairness or preventing harm sometimes backfire and can worsen parents' hesitancy, our colleague Lena Sun writes.

"A study published Monday in Nature Human Behaviour suggests a more effective way to reach vaccine-hesitant parents may be to focus on two potentially powerful moral values that underlie people’s attitudes and judgments: individual liberty and purity," Lena writes. "Compared with parents who approve of vaccines, parents who are most reluctant to vaccinate are strongly concerned with liberty and purity, the researchers found. In this framework, liberty is associated with belief in personal responsibility, freedom, property rights and resistance to state involvement in citizens’ lives. Concerns about purity center on boundaries and protection from contamination."

"The new study used a social psychology theory known as Moral Foundations Theory to assess the underlying moral values most strongly associated with vaccine-hesitant parents," Lena continues. "Their findings correspond with the reasons many vaccine-hesitant parents give for delaying or refusing some vaccines, and with many of the claims on anti-vaccination websites."

OUCH: The Veterans Affairs Department has knowingly hired physicians with past malpractice claims who have been disciplined for poor care, USA Today finds. Federal law prohibits VA from hiring doctors whose licenses have been revoked by a state board, even if they still hold active licenses in another state. Yet reporter Donovan Slack finds a troubling record for neurosurgeon John Henry Schneider, who "racked up more than a dozen malpractice claims and settlements in two states, including cases alleging he made surgical mistakes that left patients maimed, paralyzed or dead."

USA Today identified 15 malpractice complaints aimed at Schneider. Of those, four were settled and two were dropped by plaintiffs, while six other complaints were deemed valid by a trustee after Schneider filed bankruptcy in 2014. And Schneider’s hiring is not an isolated case, Donovan writes.

"A VA hospital in Oklahoma knowingly hired a psychiatrist previously sanctioned for sexual misconduct who went on to sleep with a VA patient, according to internal documents," he writes. "A Louisiana VA clinic hired a psychologist with felony convictions. The VA ended up firing him after they determined he was a 'direct threat to others' and the VA’s mission."

The VA hiring process appears rigorous from the outside, as there's a multistep vetting, verification and interview process. "But when applicants disclose prior problems with medical licensing short of revocation, malpractice or criminal histories, VA hospital officials have discretion to weigh the providers’ explanations and approve their hiring anyway," Donovan explains.


--Pharmacy giant CVS Health Corp. is moving forward with its plans to acquire top insurer Aetna for $69 billion. So what will that mean for consumers? Perhaps more health services via more clinics in the pharmacy's stores, the AP reports. CVS clinics already had services to treat basic ailments like sinus infections and strep throat and have added services like blood draws and monitoring of high blood pressure and diabetes. Some expanded services following the merger could include eye care and centers for hearing aids – creating a one-stop-shop for customers’ needs.

CVS is not alone in this frontier. The country’s largest health insurer, UnitedHealth Group Inc., also runs clinics and doctors offices and has one of the nation’s largest pharmacy-benefit management businesses, per the AP.

What does this mean for CVS's separate deal with Anthem to help that company establish its own pharmacy-benefit system? It's going forward as planned, CVS’s chief executive said yesterday. Larry Merlo said during a call with Wall Street analysts that the merger “has no bearing” on its deal with Anthem to build the drug-benefit manager (called IngenioRx), per Axios.

Of course, Anthem could always back out of the deal given CVS is now poised to acquire one of its top insurance competitors. “As part of our work to develop IngenioRx, Anthem considered various strategic possibilities and prioritized flexibility in structuring our contract to maintain the ability to adapt to a changing and dynamic marketplace if appropriate,” Anthem said in a statement following reports of the CVS-Aetna deal.

--Some more good reads from The Post and beyond:

The head of the Centers for Medicare and Medicaid Services said Monday that she expects several states to implement plans that would require people who receive healthcare coverage through Medicaid to have to work.
Washington Examiner
The legislation to fund the government for two weeks could also provide some short-term relief to help states keep their Children’s Health Insurance Programs (CHIP) afloat.
The Hill
Sen. Elizabeth Warren, D-Mass., is questioning the ability of White House adviser Kellyanne Conway to coordinate the Trump administration's efforts to fight the opioid crisis.
Washington Examiner
Health & Science
Baltimore’s prestigious medical centers make millions from emergency treatment, hospital records show.
Jay Hancock, Rachel Bluth of Kaiser Health News and Daniel Trielli of Capital News Service
Health & Science
Some regions where patients face the worst wait times, including New York and Chicago, will get more of the scarce organs.
Lenny Bernstein

POST PROGRAMMING: The Washington Post gathers top health officials, practitioners, thought leaders and advocates for a discussion about the fight against HIV/AIDS.


  • Axios hosts an event on the new era in health care.
  • The Senate Appropriations Subcommittee on Labor, Health and Human Services, Education and Related Agencies holds a hearing on addressing the opioid crisis on.

Coming Up

  • The Senate Health, Education, Labor and Pensions Committee holds a hearing on the “Implementation of the 21st Century Cures Act: Responding to Mental Health Needs” on Wednesday.
  • The Senate Special Committee on Aging holds a hearing on “America’s Aging Workforce” on Wednesday.
  •  The Senate Health, Education, Labor and Pensions Committee holds a hearing on the “Implementation of the 21st Century Cures Act: Progress and Path Forward for Medical Innovation” on Thursday.
  • The House Veterans Affairs Committee holds a hearingon the VA Medical Surgical Prime Vendor Program on Thursday.

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