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White House Opens Door to Democrats in Wake of Health-Bill Failure

WASHINGTON—The White House sent a warning shot to congressional Republicans that it may increase its outreach to Democrats if it can’t get the support of hard-line conservatives, a potential shift in legislative strategy that could affect drug prices, the future of a tax overhaul and budgetary priorities.

Days after the House GOP health bill collapsed due to a lack of support from Republicans, White House Chief of Staff Reince…

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Trump’s biggest mistake in health care failure

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Donald Trump

Maybe it’s a coincidence. But the first full business day after the GOP health insurance bill failed in Congress, the White House announced a new team to revamp the federal bureaucracy by using efficient business strategies.

That’s encouraging, because President Trump, who promised to run the country using his business smarts, fumbled the Obamacare replacement bill just like the same old partisan politicians we’ve endured for decades.

Now that Trump has learned the hard way that the phrase “this is the way Washington works” is an oxymoron, perhaps it can go forward with more confidence than ever in its own independence.

But how can the White House move forward on health care? There are many ways approaching that issue like a business person could actually succeed. Let’s look at the top five:

1) Demand? Meet supply

All business operates in the basic law of supply and demand. Government doesn’t. The first and biggest mistake politicians have been making about health policy is they continue to conflate the demand for health care with the demand for health insurance. This is no accident as politicians can really only win quick political points and grab big campaign donations if they focus on working with the existing insurance companies.

By contrast, any decent business person would simply look at the situation in the health care market and see that increasing supply via innovation and other methods are the obvious ways to lower costs and improve access and quality. That’s priority 1 because even if there were a bill that would give everyone in America great insurance coverage, it won’t be worth a dime if there aren’t enough doctors and hospitals and drugs to treat all these newly-covered patients.

2) Pricing, Pricing, Pricing

There are few things more vital to the legitimate business world than pricing transparency. That’s what makes people watch those stock tickers religiously during stock trading hours. But a clear and strong law forcing total health care price transparency didn’t make it into the GOP Obamacare replacement bill. And that’s a shame because if patients truly knew the real costs and the options they had every time they consider or are told to get a medical procedure, prices would go down. That’s a basic economic fact.

3)  Subsidies? We don’t need no stinking subsidies!

Imagine if the local electronics retailer sold flat screen TV’s at different prices to different people, depending on their income. Ridiculous. But in the political world, it makes obscene sense to sell health insurance as if supply were no issue and give out lots of subsidies in order to spread the political patronage around as much as possible.

Business people know that every seller charging the same price to any and all comers is the best way to spur more supply, more competition, and better quality. That’s why flat screen TV’s are better and cheaper with every passing year. And the opposite is why health care and health insurance are more expensive every year. Subsidies skew the system in favor of political concerns.

4) Choice, choice, choice

Only the highest end auto dealers sell super expensive cars with all the amenities with no other choices for consumers. Everyone else offers buyers the chance to pay more for more and less for less in their chosen car. And they do that to make sure they have something everyone in the marketplace could want. Politicians don’t have to do that, so Obamacare and the original form of the GOP replacement bill forced everyone to buy health insurance plans loaded with the same “essential benefits” for everyone.

And the old style “major medical” plans that the Affordable Care Act outlawed were still not resurrected by the Republican plan even in its final form. And that’s because politicians from both parties don’t want to face any backlash from any voters who may protest having to, (gasp!), pay more for more services. But the idea of having to pay more for more is a given in the marketplace and that’s just one reason why the marketplace is better than the political world.

5)  Stop bundling and go a la carte

The rise of Netflix, YouTube, Hulu, etc. has taught the cable industry a hard lesson about just how much the public dislikes paying for channels and entertainment it doesn’t want just to get the channels and entertainment it does want. The “cut the cord” movement is all about fighting back against that bundling in your cable bill and it’s a creation of the free market through and through.

Politicians haven’t learned that lesson when it comes to health bills or really any bills for that matter. Every bill is jammed with fine print and added entries that simply wouldn’t stand a chance of passage if they were examined and voted on as single items.

A good business approach would be to strip the massive health bill and other bills like it into smaller pieces that could at least be turned into “sales” much more easily. The political class likes big omnibus bills because it helps indemnify them from individual criticism and helps them avoid having to actually work with the public any more than necessary. Good business people know that the only way to succeed is never to lose that kind of connection with their customers and potential customers.

Speaking of that political disconnect versus what we see in successful businesses, there’s a real snobbery and falsity to the political class argument about how government functions. Their point is to “ensure” us that governing is so complicated that it really should be left to the experienced bureaucrats. The truth is the only complicated thing about it is the cowardly nature of the political class and its inability to govern properly.

Trump didn’t handle the health bill well, precisely because he let the political class from the GOP side handle it way too much. Trump should go more with his outsider gut, reject the nonsense of the political class, and get to work.

Commentary by Jake Novak, senior columnist. Follow him on Twitter @jakejakeny.

For more insight from CNBC contributors, follow @CNBCopinion on Twitter.


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After GOP Health Failure, Next Battle Could Shut Down Government

Republican leaders are eager to avoid a government shutdown but the demise of their Obamacare repeal could leave some conservatives spoiling for a fight that raises the odds of a standoff.

The House Freedom Caucus, which helped bring down the GOP health-care bill, says Republicans have yet to notch a significant victory, despite controlling both chambers of Congress and the White House. One top promise they and other conservatives had to hoped to deliver on with the Obamacare repeal was defunding Planned Parenthood over its provision of abortions.

Now, their next chance comes with a spending measure needed to keep the government operating after April 28, when current funding runs out. But Democrats, and some Republicans, strongly defend the group, which provides many health services to women. The battle, which nearly led to a shutdown in 2015, could be enough to set Congress on a path to another one.

“I’m very concerned and we are going to have to try and work in a bipartisan fashion,” Senate Armed Services Chairman John McCain, an Arizona Republican, said Monday.

How much leverage conservatives and the Freedom Caucus will have in future fights remains unclear. Any spending measure needs at least eight Democratic votes in the Senate to be enacted, and lawmakers on the Appropriations panels have been quietly negotiating a bipartisan spending plan to fund the government through Sept. 30, the end of the fiscal year.

QuickTake Obamacare Dodged a Bullet. What’s Next?

But conservatives, who defied personal pleas from President Donald Trump to back the Obamacare repeal bill, may feel emboldened to make demands on a stopgap, and could harangue GOP colleagues who cave in to Democratic demands. 

Trump, too, will be looking for legislative victories, which have so far been elusive. And given the sharp cuts he has proposed for non-defense spending, he may not have the same reservations as his predecessors about shutting down the government.

But John Cornyn, the No. 2 Republican in the Senate, dismissed the idea. “There’s not going to be a shutdown,” he said. “No shutdowns.”

Signs of Turmoil

More broadly, the Republican dysfunction that killed Obamacare repeal could be a sign of more turmoil ahead in Congress for other GOP plans as well, including an ambitious tax overhaul, infrastructure spending and legislation to raise the nation’s debt limit.

The Challenges Facing Paul Ryan’s Tax Reform Plans

House GOP leaders will be relying in part on Appropriations Chairman Rodney Frelinghuysen to help sell a spending measure that can make it through the House. But Republicans are angry at the New Jersey Republican, according to a GOP aide, because he came out against the health-care bill Friday, hours away from the do-or-die vote. Angry lawmakers could take it out on his committee’s legislation, the aide said.

Republican Representative Tom Cole of Oklahoma, who sits on the appropriations panel, said GOP leaders should simply advance the measure currently being negotiated, ignore the Freedom Caucus and rely on Democratic help.

“I’m sorry but we had a revolt even when we didn’t do a bipartisan approach,” he said referring to the health-care bill. “The paramount thing is to get budget stability” and look ahead to fiscal 2018 spending.

“Republicans shutting down the government would be the most politically stupid thing you could do,” he said.

‘Total Control’

Another member of the appropriations committee, Representative Tom Rooney of Florida, says he hopes that Trump will give them “cover” from the Freedom Caucus, with the argument that it’s better to just get passed this funding deadline and move on.

“If we shut down the government when we have total control, I don’t know what to tell you,” he said.

QuickTake U.S. Budget Battles

The outcome could depend on how strongly Trump sticks to his demands. The president has asked for $30 billion in emergency spending for defense, along with $18 billion in offsetting cuts in non-defense spending. Both Republicans and Democrats have said those cuts are a nonstarter. And he also wants Congress to begin spending money on a border wall, even though Democrats are mostly opposed and Republican leaders aren’t in any hurry on that issue.

The congressional calendar also leaves no room for error. Lawmakers are scheduled for a two-week recess in April, leaving very little time before the funding deadline.

Planned Parenthood could still be the biggest sticking point, but some Republicans are sounding weary of conservatives’ demands on this issue.

“Don’t come to me and ask me to do that when you had your chance and you couldn’t put up the votes for that. ” Cole said, referring to the House Freedom Caucus blocking the Obamacare repeal bill.

Risks of a Showdown

And even some conservatives are showing signs they see risks in forcing a showdown on the funding bill, particularly because the legislation will need Democratic votes to pass the Senate. 

“We can stand here and beat each other to bloody dust and get nothing accomplished,” Representative Trent Franks of Arizona, one of the most strident opponents of abortion and Planned Parenthood, said Monday.

The White House also hasn’t articulated a clear position on the issue.

When pressed Monday on whether Trump would commit to pushing to defund the group in the upcoming spending bill, White House spokesman Sean Spicer wouldn’t say, explaining he didn’t want to “get ahead of our legislative strategy.”

Trump himself tweeted on Sunday, “Democrats are smiling in D.C. that the Freedom Caucus, with the help of Club For Growth and Heritage, have saved Planned Parenthood Ocare!”

Democrats, still savoring the implosion of the Obamacare repeal effort, see little reason to give in to conservatives’ demands.

“Democrats continue to work in good faith to develop a bipartisan package that supports critical services and investments and rejects poison pill riders,” said Representative Nita Lowey, the top Democrat on the House Appropriations Committee.

Room for a Deal

Republican Senator Lindsey Graham of South Carolina, who sits on the Appropriations Committee, says he could see a deal where Democrats accept some emergency defense and border security spending in return for protection on undocumented immigrants who got protection under the Obama administration’s Deferred Action for Childhood Arrivals program.

“I do know eventually you gotta deal with these 800,000 kids. They’re going to start losing their legal status and I don’t think we as a party are going to pull them back into the shadows,” he said Monday. “I’m open minded about dealing with those kids in this package, but that’s just me.”

Indeed, while Trump has said he’s open to granting the so-called “Dreamers” some kind of protected status, several House conservatives have tried to terminate the program on previous spending bills.

‘Driving the Train’ on Taxes

Even if Republicans manage to avoid a shutdown, the Obamacare repeal incident has raised doubts, including at the White House, about the party’s ability to avoid a repeat on its next big priority: a tax overhaul.

“We’re driving the train on this,” said Spicer, signaling that Trump would take a more active role in the tax debate after delegating much of the health care tasks to Ryan.

But Spicer also said that administration — including Treasury Secretary Steven Mnuchin, economic adviser Gary Cohn and Commerce Secretary Wilbur Ross — have yet to reach agreement on a tax plan. Still unclear is whether Trump will support Ryan’s plan, which includes a controversial proposal to replace the 35 percent corporate income tax with a 20 percent levy on U.S. companies domestic sales and imports. Exports would be excluded.

Ryan and Majority Leader Mitch McConnell also have to decide whether to adopt a new fiscal 2018 budget resolution, which could be a difficult feat given conservatives’ demands that the budget needs to be balances within 10 years. They could also decide to reuse the existing fiscal 2017 resolution, which they had originally planned to use for Obamacare repeal.

The timing for tax legislation is also unclear. While Ryan is pressing to pass a bill by August, Senate leaders have also suggested it may take longer, and Spicer left open that possibility as well.

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Trump Voters Say President Can Learn From Failure of Health-Care Bill

Some of President Donald Trump’s supporters say they are disappointed by the implosion of a health-care bill on Friday, but the political fallout for him may be limited as they blame House Speaker Paul Ryan more than the president for failing to deliver on a central campaign promise.

The Wall Street Journal has identified a pool of ambivalent Trump voters—people who said in Journal/NBC News surveys last fall that they preferred Mr….

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Health Care: All for the Best

In Judaism, we have an expression that is equivalent to “It’s all for the best”: Gahm zu l’tovah – this, too, is for the good.

Nowadays, with the 24-hour news cycle, every story, big or small, is made to rival the Hindenburg Disaster, Pearl Harbor, and First Manassas.

When I watch news, I watch Fox.  I have not watched CNN, MSNBC, or any source other than Fox since the November election.  Literally.

Every three minutes, Fox does that thing with the chime: “This is a Fox News alert.”

That also is how they begin every, every program (except for O’Reilly).

The reality is that very few things really are as urgent or as concerning as reported at that moment.  They do not merit a loud chime.

With health care, if the bill is wrong or flawed, it is better that the Republicans not pass it on Trump’s 64th day.  The GOP gave it a shot.  I have no problem with their having done health care before taxes.  I avoid being a “Monday Morning Quarterback” because I myself have been “in the arena” enough times to know that every loss or setback will be second-guessed (“I told you so!”), while every success is met with “I was behind you a hundred percent.  I am glad you listened to my idea – I was going to share it with you but forgot to.”

Health care reform is tough.  It requires taking away free stuff from people.  That is very hard and unpopular to do.  In Obamacare, there are so many moving parts that any restructuring effort entailed getting into the muck and mire.  Now Paul Ryan has presented his “balanced” bill, gotten the necessary feedback, seen what can be bent, what is insoluble, and a new, better bill can be structured for next time. 

There was a bunch of great stuff in the initial effort: end funding to Planned Parenthood as long as they do abortions.  Force Medicaid recipients, who, unlike the elderly and disabled on Medicaid, really are quite able-bodied and capable of doing so, to go out and get a job.  Stop scaring companies with 49 employees so they no longer have to fear hiring a fiftieth employee and no longer feel compelled to force full-time workers into 29-hour-a-week jobs.  Lots of great stuff.  Phase 3 of Ryan’s package would have included allowing associations to bundle individuals into much lower cost group plans, to bring down premiums because large groups can economically absorb pre-existing conditions.  It would have allowed for interstate competition in health insurance, provided for much-needed tort reform in medical malpractice litigation, and required more sophisticated bidding and negotiating to bring down drug costs.  Lots of great stuff.  Meanwhile, Phase 2 of the reform plan would have expunged scores of costly and deleterious Obama regulations.  All great stuff.

But the bill had flaws.  Conservatives have our concerns; liberals have theirs.  These flaws in the first iteration of repealing and replacing Obamacare can be fixed, but they need more time and more patient negotiating.  Ryan now understands where the unmovable barriers are, where the negotiators are not bluffing.  And complicating all of it is the sheer idiocy of the arcane Senate rules that require 60 votes unless they do it via the crazy “reconciliation” rules that were refined by a former Ku Klux Klansman, the Hon. Cyclops Robert W. Byrd.  

There is nothing wrong with walking away from a negotiation and saying, “That’s it.  I’m outta here.”  In the 24-hour news cycle, it sounds like Pearl Harbor or the British burning down the White House.

But that is how I used to buy a car, before the internet offered better ways.  After half a day of negotiating, and the salesperson passing little love notes back and forth with the office manager, I would walk out.  Sometimes I never came back; sometimes I did, and they offered a better deal.

Back in 1987, I went to buy a Nissan Sentra at a famous Southern California dealership.  Two family members accompanied me.  They told me: “This dealer is amazing.  No one ever leaves without him selling the car.  He is mesmerizing.”  He and I negotiated three hours until midnight that Labor Day.  He would not agree to make a concession on which I insisted.  So, after three grueling hours, I just walked out.  My family members could not believe it: “No one ever walks out on this guy without buying a car.”  The next day, I bought a Honda Accord from a guy named Willie Wong at Woodland Hills Honda.

Over the next thirty years, I have bought six more cars – all Accords.  I love the Accord.  Nissan lost me that Labor Day.

If it were the 24-hour news cycle, they would be chiming: “Fox News alert – Man leaves without buying Nissan.  How will he ever get to work again?”  Well, no one buys a car with a “Fox News alert” chiming in his head every three minutes.  Indeed, don’t we all wish Obama and Kerry knew how to walk away from Iran when negotiating that awful sucker deal?  They would have gotten back the hostages, would not have had to send the cash in planes – and maybe even cut a half-decent deal.

It’s OK to walk away from a deal.  That is what Trump did…and good for him and Ryan.

Obamacare will implode of its own.  The Democrats put lots of sugar and candy into Obamacare’s first years, with built in time bombs to explode as of 2017, once Obama was safely out of office, golfing in Hawaii or dancing the salsa in Cuba.  Then the explosions would start.  New unpopular features would begin.  Certain government funding would be withdrawn.  The idea was to get the CBO to score the Obamacare favorably for its first year or two, to get it through Congress, with the piper being paid later.  Most average people – and, after all, aren’t most people average and mediocre by definition? – have no clue on Earth as to what is going on.

But those in the know realize that even more insurers now will be pulling out of Obamacare as subsidies expire, so even fewer insurance options will remain, and crazy-high five-figure deductibles will set in that make the policies virtually worthless.  More people will drop out as they realize that all their medical care is out of pocket anyway with such high deductibles, so why pay meaningless premiums?  In addition, because no one now will be penalized dropping out, the floodgates will open like the Exodus from Egypt.  ”Egypt me!” they will yell.  As even more drop out, with even fewer paying premiums, the premiums for those remaining in Obamacare will shoot even higher to compensate the insurers for their losses, resulting in even more people dropping out and therefore in even more insurers pulling out.  Hence, the references to Obamacare now entering a “death spiral.”

So here is what will happen these next few days: the media will make it a bad weekend for the GOP.  Pearl Harbor.  Cold Harbor.  Shiloh.  The death of Ned Stark.  Trump has lost his magic as the deal-maker.  Ryan is getting sun tan treatments to look like John Boehner, as he faces ouster.  All kinds of overheated exaggeration.

Then comes Monday, a new week.  Some idiot will accuse Manafort of plotting with Trump and Putin to win the election.  More revelations about Flynn and the Turks.  Trump will tweet something insane that absorbs a day or two of news.  And then Judge Gorsuch will get approved on party lines by the Senate Judiciary Committee, and the news focus will turn to how Trump got his judicial nominee through, and will the Democrats filibuster, and will the GOP go to the nuclear option, and no one will remember health care.  Then a great tax bill will emerge, and it will pass successfully because every Republican in Congress knows that they cannot let any more Trump initiatives slip.  The stock market will jump several hundred points.  And maybe there will be some news about infrastructure and the Big Beautiful Wall.  And then, next autumn or early next year, back to a better repeal-and-replace of Obamacare as the thing really blows up, and as Congress has to act.

And the angelic chimes will ring: “This is a Fox News alert.”

Rabbi Dov Fischer, an attorney and adjunct professor of law, is a senior rabbinic fellow at the Coalition for Jewish Values, congregational rabbi of Young Israel of Orange County, California, and holds prominent leadership roles in several national rabbinic and other Jewish organizations.  He has been chief articles editor of UCLA Law Review, clerked for the Hon. Danny J. Boggs in the United States Court of Appeals for the Sixth Circuit and served for most of the past decade on the Executive Committee of the Rabbinical Council of America.  His writings have appeared in The Weekly Standard, National Review, Wall Street Journal, Los Angeles Times, Jerusalem Post, American Thinker, Frontpage Magazine, and Israel National News.  Other of his writings are collected at

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First casualty for House Freedom Caucus after health care meltdown

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Why Republicans were in such a hurry on health care

Why were Republicans rushing to vote on a health-care plan that they’d barely finished drafting, that budget scorekeepers hadn’t had a chance to fully evaluate, and that, insofar as people did know about it, was widely despised?

In part, it’s because their plan was so unpopular and because it got more unpopular the more people learned about it. But it’s also because only by rushing to reshape a full sixth of the American economy without knowing exactly how they would be reshaping it would Republicans be able to use health care to pave the way for the rest of their agenda, including tax reform. In other words, the GOP didn’t want to let a detail like tens of millions of people losing their health insurance get in the way of two tax cuts for the rich.

Here’s what we knew about the Republican plan. The latest version that the nonpartisan Congressional Budget Office had a chance to analyze would have, over the course of 10 years, cut taxes by $1 trillion, disproportionately benefiting the rich; cut Medicaid spending by $839 billion, exclusively harming the poor and sick; and cut the Affordable Care Act’s health insurance subsidies by about $300 billion, mostly hurting older people of modest means. Add it all up, and the CBO estimated that 24 million people would have lost their health insurance as a result. Not only that, but premiums would have increased 15 percent to 20 percent more than they otherwise would have in the next four years before so many older people were priced out of the market that premiums would have started to come down, and deductibles, according to the Kaiser Family Foundation, would have been an average of $1,550 higher. In short: The GOP would have made insurance more affordable for younger people by making it unaffordable for older people and worse for everyone.

This wasn’t just a matter of higher premiums and higher deductibles, though. Trumpcare also would have repealed the “essential health benefits” that plans are required to cover now. States would have been allowed to write their own rules, so, depending on where you lived, insurance companies might have been able to sell you “insurance” that didn’t cover hospitalizations, prescription drugs, maternity care, mental health care and preventive care, and also imposed annual and lifetime limits on your benefits. People who couldn’t afford insurance that actually, you know, insured them might have bought these skimpy plans with their skimpy tax credits — why not use them on a fake something instead of a real nothing? — but neither the CBO nor they themselves likely would have thought of this as being covered.

The surprising thing, then, isn’t that as few as 17 percent of people approved of the American Health Care Act. It’s that as many as 17 percent did.

But there’s a reason the GOP was pushing a bill that would have taken everything people don’t like about the health-care system and made it worse. That’s the fact that it would have allowed them to pass two permanent tax cuts for the rich. Anyone, you see, can pass a tax cut that expires after 10 years. But if you want to make it last — and you don’t have 60 votes in the Senate — then you need to find a way to pay for it (or at least look like you did). Taking health insurance away from poor and sick people would have done just that for the Obamacare taxes, which primarily hit people in the top 1 or 2 percent. Indeed, as you can see below in the chart from the Urban Institute, the combination of tax cuts for the rich and benefit cuts for the poor that was the GOP health-care plan would have been a reverse Robin Hood that redistributed income from people making $50,000 or less to mostly those making $200,000 or more.

Now, the crazy thing is that this first tax cut for the rich (in the form of Obamacare “repeal and replace”) would have made a second one (this one coming in the form of “tax reform”) look more affordable.

That’s because, due to parliamentary rules, tax revisions can’t lose any revenue outside the 10-year budget window if it’s going to be permanent. The question, though, is lose revenue compared to what. If Republicans had repealed the Affordable Care Act’s $1 trillion worth of taxes before they revised taxes, that’s $1 trillion less they’d have to come up with to make it look like money wasn’t being lost. Now, without those phantom savings, tax restructuring, Speaker of the House Paul D. Ryan (R-Wis.) admitted, will be “more difficult.” Not that it was ever going to be easy. After all, the $1 trillion they were trying to save with a “border adjustment tax” seems to be on political life support, since every major retailer, including big GOP donors such as Walmart, is opposed to it. And, as you might have guessed, there aren’t an extra $2 trillion of savings lying around for them to replace the ones they thought they were going to get from this and repealing the Affordable Care Act.

Which is to say that Republicans will either have to scale back their ambitions for how deeply they will cut taxes or how long they will. Whatever they choose, though, the top tax rate isn’t going to stay under 30 percent.

And for the GOP, that’s the real tragedy of 24 million people keeping their health insurance.

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Report: Trump ‘upset’ with Kushner over vacation prior to health care bill vote

President Trump is reportedly “upset” that his senior adviser and son-in-law Jared Kushner were on vacation as he and other Republicans were losing the battle over health care.

CNN quotes an unnamed inside source as saying, “[Trump] is upset that his son-in-law and senior adviser was not around during this crucial week.”

Instead, Kushner and his wife, first daughter Ivanka Trump, were photographed on a skiing vacation in Aspen, Colorado, with family.

Vanity Fair points out that “The Aspen trip’s timing may have some questioning how loyal or serious the daughter and son-in-law are about their roles within the White House. But their absence also allows them some distance, and immunity, from the mess that has unfolded in Washington.”

The publication says, the pair also went on vacation in August of last year during a particularly low time in Donald Trump’s campaign.

RELATED: Ivanka Trump Jared Kushner

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Nevertheless, the piece argues that, unlike other advisers, Ivanka and Jared are family and extremely loyal to the president so their standing with him is secure.

CNN noted, “A White House spokesperson flatly denied the President is frustrated with Kushner.”

Trump did blame one group for the failed health care bill. During a press briefing Friday afternoon, he slammed Democrats for their lack of support.

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What Next for Health-Care Reform? Possible Strategies for the GOP

The death of the American Health Care Act has been greatly exaggerated — not because it is likely to be revived (at least in its current form) but because it might never have really been alive in the first place.

Many of the provisions of the bill were unlikely to survive contact with the Senate, and there was a very strong chance that the bill that was released from a House–Senate conference would radically differ from the AHCA. Perhaps realizing the limits of the AHCA, some defenders of the AHCA supported the measure principally as a way of getting to conference. However, there is no reason to believe that the tensions that pulled down the AHCA on Friday would not similarly undo the resulting House–Senate conference bill. Some Republicans would still be upset that the conference bill was not a full repeal of the Affordable Care Act, and moderates (along with some populists) would be pulled into a tug-of-war with budget-cutters over the size of Medicaid cuts.

Matthew Continetti has observed that the American Health Care Act allowed procedure to dictate policy. Because the bill was designed to be passed through reconciliation, it focused on the government financing of health care. When at the eleventh hour Utah senator Mike Lee suggested that the Senate parliamentarian might allow certain regulations to be changed, regulatory changes were quickly added to the bill. But that was all too late and too fast. Moreover, the fact that the AHCA was essentially a tax- and entitlement-reform bill caused it to accentuate tensions between populists and other factions of the GOP.

There is no inherent reason, though, why the main Republican effort at health-care reform has to be done through reconciliation. In fact, there are some ways in which trying to pass health-care reform through reconciliation is worse in terms of policy and political outcomes. A reconciliation-centric strategy nearly guarantees that the GOP health-care effort will be passed on a party-line vote, which means that Republicans will own all the warts of the resulting health-care system. Moreover, because reconciliation is mostly limited to finance-related pieces of legislation, the reconciliation process gives Republicans less room to promote an expansive reform effort, which would allow for more far-reaching reforms to the medical system. The fact that a reconciliation-oriented bill does not include these important reforms makes it more likely that there will be more policy warts for Republicans to be the lucky owners of. The policy limitations of a reconciliation effort compound the political dangers.

Republicans do not need to return to health-care reform immediately. There are many other issues, from infrastructure to immigration, that would more closely align with the animating issues of the Trump campaign and where important reforms are needed. However, there could be a political risk in not making some attempt at health-care reform. Republicans have had significant electoral victories over the past few cycles in part because of public frustration with the many shortcomings of the Affordable Care Act, and the U.S. medical system is in need of reform. If Republicans do return to health care, they could simply seek an outright repeal of the Affordable Care Act. They could also try to pass a slightly different bill through reconciliation or offer a more comprehensive health-care bill that does not need to go through reconciliation. Or they could use some combination of these strategies. But whatever approach they take, Republicans might be wise to develop an affirmative vision for health-care policy.

Pascal-Emmanuel Gobry has argued that conservatives should do the following policy two-step: “Slash regulations. And then subsidize health care.” There’s a certain logic to this process. It would allow Republicans to focus on health-care efforts that might be more popular (market-oriented reforms) while avoiding parts that might be more divisive (such as cutting Medicaid for the poor and working class). Rather than “repeal and replace,” it could instead be called “reform and retain.” Medical regulations could be reformed (including many of the new regulations in the ACA), but many subsidies for low-income Americans would be retained. Reform and retain might end up repealing many elements of the ACA, but the focus would be on improving the American health-care system — not simply eliminating the ACA. (Of course, the Affordable Care Act has inflicted damage on the health-care system, and any effort at reform would have to confront those injuries.)

Republicans do not need to return to health-care reform immediately. However, there could be a political risk in not doing so eventually.

A way of promoting reform and retain might be to design a moderate health-care bill that prioritizes reforming the insurance system (by expanding insurance options, for instance) and the medical-delivery system. It might include allowing insurance to be sold across state lines, increasing the number of medical residencies, or devising mechanisms to encourage more-diverse forms of licensing. This measure might include some tax incentives to help purchase medical insurance, and it might repeal or revise certain taxes (such as the medical-device tax). But the main goal would be to promote policies that would make the medical industry more competitive, more nimble, and more responsive to consumers. Over the long term, these efforts would hopefully reduce the cost of medical care.

Along with these reforms, many health-care subsidies for the poor and working class might be retained, though the precise financing mechanisms might be changed. A health-care bill that keeps subsidies in place would certainly not please everyone in the Republican coalition. Members of the House Freedom Caucus might be upset about the continued government spending on Medicaid, and market-oriented reforms might irritate some corporate lobbyists. But this approach would have the advantage of advancing the principles of innovation while protecting Republicans from accusations that they are indifferent to the poor. Members of the Freedom Caucus might accept a bill that continues some government subsidies while also reforming the health-care system in order to reduce the demand for even more subsidies.

Moreover, a reform-and-retain bill could put some Democrats in a tough spot. It would make the political battle not about how much to cut Medicaid but instead about how much to expand the diversity of insurance products and medical-delivery institutions. Austerity politics are often a loser in American life, but market-oriented reforms have a stronger track record.

Senate Democrats might intend to use the filibuster to block any significant piece of legislation, hoping that political paralysis will replenish their congressional majorities in 2018. But that strategy runs into trouble if Republicans offer moderate measures with broadly popular policy centerpieces. Then, Democrats risk looking out of touch and partisan. That risk for Democrats is especially great on health care: Republicans can say that they are trying to remedy the defects of the Affordable Care Act but Democrats are blocking these middle-of-the-road reforms.

A swing-state Democratic senator like Bob Casey (Pa.) could fairly easily justify voting against a Republican health-care-reform bill that cuts Medicaid. He’d have a much harder time opposing a bill that keeps Medicaid subsidies in place, offers some tweaks to the financing of health care, and makes significant reforms to the health-care market. Swing-state Democrats may decide that going along with these centrist, market-oriented reforms would be politically safer than trying to block them. And if Democrats do block that kind of reform, Republicans could use that to hammer then in the 2018 midterms. For conservatives, good policy and good political outcomes could follow.

Beltway hysterics to the contrary, the failure of the American Health Care Act on Friday was not an extinction-level event for Republicans; in fact, the grave political risks associated with passing the AHCA helped deny it a majority in the House. Still, this failure might teach Republicans that more work still has to be done in developing conservative policies that address current problems and that can win popular support.

— Fred Bauer is a writer from New England. He blogs at A Certain Enthusiasm.

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Health-Care Reform Won’t Fix What Really Hurts American Health

In 2016, two truths were revealed at once. First, the percentage of uninsured Americans hit a record low — a mere 8.6 percent. In 2010, almost 50 million Americans lacked health insurance. By the beginning of 2016 that number had plunged to 27.3 million. This is, truth be told, the fruit of Obamacare and indeed is the very reason why the GOP is having so much difficulty in its struggle to repeal and replace it. People like having health insurance, and health insurance makes us healthier, right?

But that brings us to the second truth that was revealed in 2016. Even though Americans allegedly enjoyed unprecedented access to insured health care, the nation’s death rate in 2015 actually increased. More Americans were insured, but more Americans died. Why?

A clue comes from Princeton economists Anne Case and Angus Deaton, the same people who shocked America two years ago with research showing the remarkable rise of the death rate among middle-aged white Americans. This week, they released new research showing that the trend continues. “Deaths of despair” are “surging” in the United States. The chart below is nothing short of stunning:

Even worse, other data show younger-age cohorts are at significantly greater risk of death by drugs, alcohol, or suicide than their elders were: Men and women in early middle life began exhibiting by their twenties the same kinds of death rates from drug, alcohol, and suicide as were formerly reserved for much older men enduring the stereotypical “mid-life crisis.”

Indeed, these charts may actually understate the extent of “deaths by despair.” The obesity epidemic is carrying with it increases in chronic health conditions, including diabetes and heart disease, and make no mistake — obesity is exploding in the United States. The YouTube video below silently and ominously charts a stunning, national increase:

As Congress debated Obamacare repeal, I had lunch with a local critical-care doctor who seemed oddly indifferent to the outcome. His is a world dominated by addiction. “If it weren’t for addicts,” he says, “I wouldn’t have a job.” The intensive-care unit is overrun with people addicted to drugs, to alcohol, to food, and to tobacco. Insurance matters to the economics of the hospital, but it doesn’t matter so much to the quality of its patients’ immediate care or to their ultimate health outcome. They’re killing themselves, and the best health care and the most luxurious “Cadillac” health plans won’t stop their slide into oblivion.

It’s too simple to say that health insurance and the current debate in Washington doesn’t matter to public health. It obviously does. But it’s fair to say that it may well matter less than healthy marriages, strong families, decent jobs, and a vibrant faith. Deaton described the plight of the white working class well: “Your family life has fallen apart, you don’t know your kids anymore, [and] all the things you expected when you started out your life just haven’t happened at all.” And so, to “soothe the beast,” you turn to substances, to food, and — sometimes — ultimately to death itself.

Just as there is no simple solution to this crisis, there is no simple explanation. For every attempt at a short summary — it’s about jobs; it’s about marriage; it’s about welfare and dependency — there’s an answer that complicates the picture. For example, black families have had more economic struggles (and have had more out-of-wedlock births) than white families, yet for years their death rate fell while the white rate rose. Could the vibrancy of the black church and the apparently (substantially) greater religiosity of black Americans help explain a degree of healthy resilience in the face of economic, familial, and racial adversity? As the Pew Research Center notes, “African-Americans are markedly more religious on a variety of measures than the U.S. population as a whole, including level of affiliation with a religion, attendance at religious services, frequency of prayer and religion’s importance in life.”

Unless our citizens can find a way to soothe the despair, the great health-insurance debate from 2009 to 2016 may end up a mere footnote in public-health history. At the end of the day, neither the best nor the worst insurance can cause a man to put down his pills, throw out his whiskey bottles, or walk more and eat less. When the human heart aches, an insurance card won’t ease the pain.

— David French is a staff writer for National Review, a senior fellow at the National Review Institute, and an attorney.

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