Tag Archives: health care

GOP plans to cut Medicaid would jeopardize critical health services for Wisconsin students

Wisconsin’s schools receive more than $107 million in federal Medicaid funds each year, according to data released by the Washington, D.C.-based Center on Budget and Policy Priorities. That amount is higher than in all but six other states.

The Medicaid funding pays for health care services for many of the students with disabilities, such as mental health and speech therapy. It also covers vision and dental screenings provided in schools to Medicaid-eligible children and helps schools connect low-income children to other health care services that aren’t provided in schools, but are critical to a child’s development.

“Medicaid plays a very important role in supporting students in Wisconsin’s schools. Schools depend on these payments to help provide services like speech therapy, social work services, and personal care so students with disabilities can be successful at school.” said Sally Flaschberger, lead advocacy specialist at Disability Rights Wisconsin.

House Republicans tentatively plan to bring up a health bill this week, the American Health Care Act, which would cut federal Medicaid funding by $839 billion over the next decade.

In addition to putting health care at risk for millions of adults, these efforts would jeopardize critical health-related services for students and put an important source of funds for schools and states at risk.

Jon Peacock, research director of the Wisconsin Council on Children and Families, said federal cuts to Medicaid could be especially difficult for schools in Wisconsin.

“Because our schools have done a good job of utilizing federal assistance to support school-based health services, we rank seventh highest nationally in federal Medicaid spending in schools,” Peacock said.

Medicaid provides health care for more than 1.1 million Wisconsinites, including about 500,000 children, but Peacock said many people are unaware of its significance for schools.

That’s not the case for school nurses, who are well aware of Medicaid’s importance for schools, according to Valerie Hon, president of the Wisconsin Association of School Nurses.

“Without the support they get from Medicaid, some Wisconsin schools would struggle to afford keeping school nurses and other specialized instructional support personnel on staff, give students with disabilities the services they need and are entitled to receive, and provide basic screenings for Medicaid-eligible children,” Hon said. “Policymakers in Washington should protect Medicaid — not cut it.”

According to the new report by the Center on Budget and Policy Priorities, 68 percent of school superintendents reported earlier this year that they used Medicaid funding to keep school nurses, school counselors, speech therapists, and other health professionals on staff.

Peacock said the proposed changes in health care spending would have broader implications for schools. “Medicaid cuts are also likely to impede efforts to help schools implement proven reforms such as hiring and retaining excellent teachers, reducing class sizes, and expanding the availability of high-quality early education — keys to helping all children thrive in school.”

Health care in America: An employment bonanza and a runaway-cost crisis

In many ways, the health care industry has been a great friend to the U.S. economy. Its plentiful jobs helped lift the country out of the Great Recession and, partly due to the Affordable Care Act, it now employs 1 in 9 Americans — up from 1 in 12 in 2000.

As President Donald Trump seeks to fulfill his campaign pledge to create millions more jobs, the industry would seem a promising place to turn. But the business mogul also campaigned to repeal Obamacare and lower health care costs — a potentially serious job killer. It’s a dilemma: One promise could run headlong into the other.

“The goal of increasing jobs in health care is incompatible with the goal of keeping health care affordable,” said Harvard University economist Katherine Baicker, who sees advantages in trimming the industry’s growth. “There’s a lot of evidence we can get more bang for our buck in health care. We should be aiming for a health care system that operates more efficiently and effectively. That might mean better outcomes for patients and fewer jobs.”

But the country has grown increasingly dependent on the health sector to power the economy — and it will be a tough habit to break. Thirty-five percent of the nation’s job growth has come from health care since the recession hit in late 2007, the single-biggest sector for job creation.

Hiring rose even more as coverage expanded in 2014 under the health law and new federal dollars flowed in. It gave hospitals, universities and companies even more reason to invest in new facilities and staff.  Training programs sprang up to fill the growing job pool. Cities welcomed the development — and the revenue. Simply put, rising health spending has been good for some economically distressed parts of the country, many of which voted for Trump last year.

In Morgantown, W.Va., the West Virginia University health system just opened a 10-story medical tower and hired 2,000 employees last year. In Danville, Pa., the Geisinger Health System has added more than 2,200 workers since July and is trying to fill 2,000 more jobs across its 12 hospital campuses and a health plan. Out West, the University of the UCHealth system in Colorado expanded its Fort Collins hospital and is building three hospitals in the state.

In cities such as Pittsburgh, Cleveland and St. Louis, health care has replaced dying industries like coal and heavy manufacturing as a primary source of new jobs. “The industry accounts for a lot of good middle-class jobs and, in many communities, it’s the single-largest employer,” said Sam Glick, a partner at the Oliver Wyman consulting firm in San Francisco. “One of the hardest decisions for the new Trump administration is how far do they push on health care costs at the expense of jobs in health care.”

House Republicans, with backing from Trump, took the first swipe. Their American Health Care Act sought to roll back the current health law’s Medicaid expansion and cut federal subsidies for private health insurance. The GOP plan faltered in the House, but Republican lawmakers and the Trump administration are still trying to craft a replacement for Obamacare.

Neither the ACA nor the latest Republican attempt at an overhaul tackle what some industry experts and economists see as a serious underlying reason for high health care costs: a system bloated by redundancy, inefficiency and a growing number of jobs far removed from patient care.

Labor accounts for more than half of the $3.4 trillion spent on U.S. health care, and medical professionals from health aides to nurse practitioners are in high demand. But the sheer complexity of the system also has spawned jobs for legions of data-entry clerks, revenue-cycle analysts and medical billing coders who must decipher arcane rules to mine money from human ills.

For every physician, there are 16 other workers in U.S. health care. And half of those 16 are in administrative and other nonclinical roles, said Bob Kocher, a former Obama administration official who worked on the Affordable Care Act. He’s now a partner at the venture capital firm Venrock in Palo Alto, Calif.

“I find super-expensive drugs annoying and hospital market power is a big problem,” Kocher said. “But what’s driving our health insurance premiums is that we are paying the wages of a whole bunch of people who aren’t involved in the delivery of care. Hospitals keep raising their rates to pay for all of this labor.”

Take medical coders. Membership in the American Academy of Professional Coders has swelled to more than 165,000, up 10,000 in the past year alone. The average salary has risen to nearly $50,000, offering a path to the American Dream.

“The coding profession is a great opportunity for individuals seeking their first job, and it’s attractive to a lot of medical professionals burned out on patient care,” said Raemarie Jimenez, a vice president at the medical coding group. “There is a lot of opportunity once you’ve got a foot in the door.”

Some of these back-office workers wage battle every day in clinics and hospitals against an army of claims administrators filling up cubicles inside insurance companies. Overseeing it all are hundreds of corporate vice presidents drawing six-figure salaries.

Administrative costs in U.S. health care are the highest in the developed world, according to a January report from the Organization for Economic Cooperation and Development. More than 8 percent of U.S. health spending is tied up in administration while the average globally is 3 percent. America spent $631 for every man, woman and child on health insurance administration for 2012 compared with $54 in Japan.

America’s huge investment in health care and related jobs hasn’t always led to better results for patients, data show. But it has provided good-paying jobs, which is why the talk of deep cuts in federal health spending has many people concerned.

Linda Gonzalez, a 31-year-old mother of two, was among the thousands of enrollment counselors hired to help sign up Americans for health insurance as Obamacare rolled out in 2014. The college graduate makes more than $40,000 a year working at an AltaMed enrollment center, tucked between a Verizon Wireless store and a nail salon on a busy street in Los Angeles.

In her cramped cubicle, families pull up chairs and sort through pay stubs and tax returns, often relying on her to sort out enrollment glitches with Medicaid. As the sole breadwinner for her two children, ages 9 and 10, she counts on this job but isn’t sure how long it will last.

“A lot of people depend on this,” she said one recent weekday. “It’s something I do worry about.”

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. This work is published here under a Creative Commons license. 

Trump signs measure reversing Obama era rule protecting women’s access to basic health care

President Donald Trump on April 13  signed a resolution allowing states to restrict how federal funds for contraception and reproductive health are spent.

“This is a major pro-life victory,” said the House Speaker Paul Ryan, R-Wis.

Abortion rights advocates had an opposite reaction.

Under the Congressional Review Act, which allows lawmakers to repeal newly minted rules, both the House and Senate had passed a resolution killing Obama’s regulation that had protected federal grants for clinics in states wanting to block the funding.

States such as Texas in recent years have kept the grants from going to clinics as part of the country’s longstanding fight over abortion. Broadly, many Republicans seek to restrict abortion or make it illegal while Democrats have fought to keep abortion legal.

The resolution had narrowly passed the U.S. Congress, with Vice President Mike Pence called to the Senate on March 30 to break a tie vote in the chamber, where Republicans hold a slim majority.

The grants, known as “Title X” funds, were already barred from going directly to abortion services but under the now-null regulation family planning clinics had been assured they could receive money even in the face of state objections.

“Allowing states to withhold Title X funding from family planning clinics won’t make anyone safer or healthier — it will instead place essential services out of reach,” said Diane Horvath-Cosper, a medical doctor and fellow at Physicians for Reproductive Health.

She said for many people the clinics are the only place where they can receive affordable health services such as disease testing.

Planned Parenthood issued a statement that denounced the signing of the resolution. The statement said the bill Trump signed does not “defund” Planned Parenthood, but this “latest move could embolden states to try to block access to health care through Title X, both at Planned Parenthood health centers and independent clinics. These types of actions are already illegal, as a court in Florida found just this past summer.”

Dawn Laguens, executive vice president of Planned Parenthood Federation of America, said, “People are sick and tired of politicians making it even harder for them to access health care and this bill is just the latest example. Planned Parenthood strongly opposes President Trump’s willingness to undermine millions of women’s access to birth control through the Title X family planning program. Four million people depend on the Title X family planning program, and by signing this bill, President Trump disregards their health and well-being.”

Consider actions in the past three months by the Trump administration and anti-women’s health members of Congress:

• Trump reinstated and expanded the global gag rule, meaning a range of health organizations combating HIV or the spread of Zika will be banned from all U.S. global health funding if they also happen to provide counseling, referrals, or services for safe and legal abortion.

• The House considered a bill to repeal the ACA that would have prohibited women from getting care at Planned Parenthood through the Medicaid program, ended maternity coverage for millions of women and imposed a ban on insurance coverage for abortion.

• Extremists in Congress attempted to revive the failed ACA repeal bill by trading away women’s health and proposing to gut the essential health benefits provision, which would roll back maternity care, raise insurance rates for women and reduce access to birth control and other reproductive health care.

• The Senate confirmed anti-women’s health nominee Judge Neil Gorsuch, to the Supreme Court.

• The Trump administration eliminated U.S. funding for UNFPA, an organization whose mission is to champion maternal and child health across the globe.

Laguens said, “Women marched in historic numbers the day after the inauguration because they feared the worst. Their worst fears are now coming true. We are facing the worst political attack on women’s health in a generation as lawmakers have spent the past three months trading away women’s health and rights at every turn. That’s why women are the core of the resistance and have have been organizing and speaking out since the day after the election. They know speaking up and speaking out can change the direction of this government.”

ACLU files suit in Wisconsin over denial of coverage for transgender state employees

Wisconsin’s state university system and insurance board were sued on April 7. The claim from the national ACLU, ACLU of Wisconsin and volunteer attorneys from the law firm Hawks Quindel says the state refuses to provide gender-affirming health insurance coverage to employees who are transgender.

The suit was filed on behalf of Alina Boyden, a graduate student at the University of Wisconsin-Madison, and Shannon Andrews, a cancer researcher at the University of Wisconsin Medical School.

“The state continues to deny our clients coverage for medically necessary treatment simply because they are transgender, in violation of Title VII of the Civil Rights Act and the Equal Protection Clause of the Fourteenth Amendment,” stated John Knight, of the ACLU’s national Lesbian, Gay, Bisexual, Transgender and HIV Project. “All that transgender people like Alina and Shannon are asking for is to be treated like everyone else, and that includes respect and coverage for the health care you need.”

The Group Insurance Board approved coverage for such medically necessary care in July 2016, but under pressure from the state attorney general, voted in closed session to rescind these essential benefits in December.

The clients are two transgender state employees who filed challenges to the exclusion with the federal Equal Employment Opportunity Commission, and are now seeking relief in federal court.

“Many people can relate to paying into an insurance plan only to be told that the treatment they need is not covered,” Andrews stated.  “But when the reason you are denied coverage is because of who you are, it is even more painful. And it’s clearly discrimination.”

“Too many transgender people continue to face discrimination in all facets of life, including health care access, and so I felt compelled to stand up and try to do something about it,” said Boyden.

“The state should not be playing games with its transgender employees’ essential medical needs,” said Chris Ott, ACLU of Wisconsin executive director. “It has cruelly backtracked on its promise to provide access to care that the medical community agrees is necessary. Most people would hate to have the government make health care decisions for them. Our clients have experienced both, and it needs to stop.”

The legal team for the plaintiffs includes Larry Dupuis of the ACLU of Wisconsin, John Knight of the ACLU’s LGBT & HIV Project and Nick Fairweather and Mike Godbe of the law firm Hawks Quindel.

On the web

The complaint is online here.

Federal judge blocks mandatory ultrasounds 18 hours before abortions

A federal judge has blocked an Indiana mandate forcing women to undergo an ultrasound at least 18 hours before having an abortion, ruling that the requirement is likely unconstitutional and creates “clearly undue” burdens on women, particularly low-income women.

U.S. District Judge Tanya Walton Pratt’s ruling grants a preliminary injunction temporarily blocking the ultrasound waiting period.

Planned Parenthood of Indiana and Kentucky and the American Civil Liberties Union of Indiana had sued the state last July, contending the mandate was unconstitutional and would prevent some women from getting abortions.

Pratt’s ruling said the waiting period “creates significant financial and other burdens” on Planned Parenthood and its patients, particularly low-income women who face lengthy travel to one of only six Planned Parenthood health centers that can offer an informed-consent ultrasound appointment.

The judge, who heard arguments in the case in November 2016, found that Indiana provided no compelling evidence that requiring an ultrasound at least the day before an abortion, rather than on the same day, “makes it any more likely that a woman will choose not to have an abortion.”

“Given the lack of evidence that the new ultrasound law has the benefits asserted by the State, the law likely creates an undue burden on women’s constitutional rights,” she wrote.

The requirement that women undergo ultrasounds at least 18 hours before having an abortion had replaced a previous Indiana provision that required women to get an ultrasound before having an abortion but did not specify when that had to occur.

Planned Parenthood said in its lawsuit that under the earlier measure the group performed ultrasounds on women immediately prior to their abortions.

The ultrasound mandate is part of a wide-ranging abortion restrictions law that took effect July 1, 2016, a day after Pratt blocked the law’s provision that would have banned abortions sought because of a fetus’ genetic abnormalities, such as Down syndrome. The judge also blocked a provision requiring that aborted fetuses be buried or cremated.

Then-Indiana Gov. Mike Pence, who is now vice president, signed the legislation into law in March 2016.

 

LGBT rights group releases health care index

The Human Rights Campaign Foundation released its 10th edition of the Healthcare Equality Index. Of the  facilities surveyed, 303 earned HRC’s “Leader in LGBTQ Healthcare Equality” designation.

HRC also assigned numerical scores to the health care facilities — three quarters of the facilities that participated in the survey scored 80 points or above.

In a press statement, HRC president Chad Griffin said the index “reminds us again that though we have made tremendous gains over the past decade, there is still much more work left for us to do.”

 

A look at the scores…

In the 2017 report, 303 facilities — 51 percent of those actively participating in the survey — met HRC’s criteria to earn the “Leader” designation.

Health care facilities in Wisconsin to receive the “Leader” designation include: NorthLakes Community Clinic in Iron River, American Family Children’s Hospital in Madison, University of Wisconsin Hospital and Clinics in Madison, UW Health at American Center in Madison, VA William S. Middleton Memorial Veterans Hospital in Madison, AIDS Resource Center of Wisconsin in Milwaukee, Froedtert Memorial Lutheran Hospital in Milwaukee and VA Clement J. Zablocki Medical Center in Milwaukee.

Another 144 facilities earned a “Top Performer” designation for scoring between 80 and 95 points.

In addition to the scoring criteria, the 2017 HEI included a fifth section focusing on responsible citizenship and calling out activity that would undermine LGBTQ equality or inclusive patient care. Healthcare facilities may have 25 points deducted from their score for a large-scale official or public anti-LGBTQ blemish on their records.

This year, Johns Hopkins Hospital became the first and only facility to receive this deduction.

Of the hospitals that did not actively participate in the 2017 HEI but were scored based on HRC’s research, only 61 percent have nondiscrimination policies that include both “sexual orientation” and “gender identity” and only 52 percent were found to have an LGBTQ-inclusive employment non-discrimination policy.

However, HRC said 95 percent of these facilities were committed to equal visitation, close to the rate of the facilities that actively participated in the survey.

HRC highlighted in the survey report the work taking place at two transgender youth clinics — GENECIS at Children’s Health in Dallas and the Center for Child and Adolescent Gender Care at Duke Children’s Hospital in Durham, North Carolina.

Legislative attacks on the transgender communities in both states underscore the importance of the care and affirmation these clinics are providing transgender youth, according to HRC.

Priebus a central figure in Trump’s White House drama

In the behind-the-scenes drama of who’s up and who’s down in Donald Trump’s White House, chief of staff Reince Priebus is playing a starring role.

Priebus, a Midwesterner with deep ties to the Republican establishment that Trump toppled, has faced questions about his future since the day he set foot in the West Wing.

And the focus on him is intensifying following Trump’s failure to get enough GOP lawmakers to support a White House-backed health care bill, an embarrassing blow for the new president.

There’s blame to spare for the health care debacle at both the White House and on Capitol Hill. But Priebus is a particularly rich target, given that his value to Trump is tied to his relationships with GOP lawmakers, many of whom were elected during his six years as chairman of the Republican National Committee.

“Reince doesn’t have a magic wand,” said Henry Barbour, a friend and Republican national committeeman. “He doesn’t have an ability to make people do what they don’t want to do — and he doesn’t want to.”

Priebus’ standing in the White House has broad implications for Trump’s agenda.

Beyond Vice President Mike Pence, he represents the president’s most direct link to the traditional underpinnings of the Republican Party.

Trump has voiced confidence in Priebus in recent conversations with associates, including after House Speaker Paul Ryan pulled the health care bill off the floor last week, and White House officials say the two men appear to have developed a comfortable relationship.

During the Republican primary, Priebus, 45, often remarked to colleagues that he spoke with Trump more than any of the other 17 GOP candidates. The president likes to make good-natured digs at Priebus in public remarks, joking about his “crazy name” and telling a meeting of auto industry executives that his chief of staff might end up running a car company someday.

Priebus inspires intense loyalty among those who worked with him at the RNC, several of whom followed him to the White House, including press secretary Sean Spicer.

“He wants input, he wants buy-in, he wants people to feel like they’re part of the process,” said Katie Walsh, who worked alongside Priebus at the RNC and is now deputy chief of staff at the White House.

But one White House official said Priebus’ approach backfired early in the administration, leaving the impression that he was a pushover who didn’t have full control of the staff.

His style has also created uncertainty on Capitol Hill, where Republican lawmakers sometimes get conflicting messages from top White House officials, including during the health care debate and on a tax overhaul.

A GOP leadership aide said Priebus himself appears to be less involved in shaping the details of Trump’s agenda and more focused on trying to get White House officials on the same page.

The aide was among about a dozen White House officials, Trump associates and congressional aides who spoke about Priebus, some on the condition of anonymity in order to disclose private conversations.

Priebus is said to be sensitive to the criticism that has sprouted up about him, particularly when it’s focused on his competency and management of the West Wing. That’s created a mild sense of paranoia among his allies, according to another White House official, leading them to respond in outsized ways, both privately and publicly.

“He’s somebody that always hears footsteps,” the official said of Priebus.

He’s had to adjust the traditional role of chief of staff to fit a highly unconventional president. Unlike many of his predecessors, Priebus spends much of his day by Trump’s side and typically sits in on his meetings with CEOs and other outside visitors.

Priebus supporters say he has moved to tighten the reins in the West Wing in recent weeks, leading crisper discussions in his daily 8 a.m. staff meeting and taking a tougher line with those who veer from the day’s plans.

So now what? Options for consumers as health law drama fades

The Republican health plan designed to replace the Obama-era health law known as the Affordable Care Act would not have taken full effect for a few years — and now it’s dead. But many people still face questions about getting insurance for next year, including on the government run exchanges.

WILL I HAVE PLANS TO CHOOSE FROM?

It depends on where you live. Choices are dwindling, but chances are at least one insurer will sell in your market. That company may offer several plans.

Generally, big cities will have more choices than rural areas where there may not be enough customers to attract insurers.

As of now, there are 16 counties in a region of Tennessee around Knoxville that have no insurers committed to sell coverage on the exchange next year. About a third of the nation’s 3,100 counties are down to just one insurer.

Insurers have been pulling back, and more are expected to leave, but health care researchers are not predicting mass defections.

“For most consumers, (2018) will look a lot like ‘17,” said Dan Mendelson, president of the consulting firm Avalere.

Customers can try to find coverage outside their exchange, but then they won’t be able to use tax credits to help pay the bills, which may be particularly painful since many markets have seen prices soar.

 

ARE THERE FIXES IN STORE?

Last month, the Health and Human Services Department, which runs exchanges in many states, proposed some adjustments to try to stabilize these marketplaces.

For example, insurers want greater scrutiny of people who sign up for coverage outside of the open enrollment period. Customers are supposed to be allowed to do so only if they have a life-changing event like the birth of a child, a marriage, or the loss of a job that provided coverage, but insurers have found that people are just waiting to sign up when they need care.

Another proposed adjustment would let insurers design cheaper plans tailored to younger people who may not need lots of health care but want to be protected in the event of a big injury or sickness. That could be very helpful, because insurers say they have struggled to attract younger and healthier customers to the marketplaces to balance out the claims they pay from those who use their coverage.

Those changes are expected to be finalized in the next month or so.

 

WHEN WILL INSURERS MAKE THEIR DECISIONS ON 2018?

Some have said they want to see the final version of the proposed federal adjustments before deciding where and what kinds of coverage they will offer.

But insurers generally have to decide by this spring whether they will participate in order to leave enough time for regulatory approvals and marketing before enrollment starts next fall.

Aetna, the nation’s third largest insurer, has set an April 1 deadline for deciding on 2018. The company has already pared its marketplace participation down to 4 states this year from 15 because of heavy financial losses.

Customers won’t know for certain who is selling on their exchanges until early next fall. While insurers have to apply to sell coverage on their exchanges generally by late spring or early summer, they can drop out later.

 

IS THE AFFORDABLE CARE ACT ‘IMPLODING’ AS PRESIDENT TRUMP HAS SAID ON TWITTER?

No. The marketplaces are not expected to dissolve next year, even though choices have dwindled.

While there’s debate over the law’s tax burdens and its impact on government budgets, the federal plan has covered more than 20 million people.

About 11 million are covered through an expansion of Medicaid, the health program designed to help poor Americans. Another 12 million buy private insurance through the law’s marketplaces, most with help from subsidies based on income.

Analysis: The outsider dealmaker faltering in White House

Donald Trump campaigned as an outsider — celebrating his lack of political experience by selling himself as a dealmaker willing to buck Republican orthodoxy and his own party’s leadership. He alone would reshape Washington.

He’s tried governing the same way.

His actions are a blitz.

He rarely consults old Washington hands.

And he hangs the threat of retribution over anyone who challenges him.

And now he and his party have been dealt a stinging defeat on a signature campaign promise, a defeat that further weakens a president whose approval rating has hovered under 40 percent and humiliates Republicans who have pledged for seven long years to undo President Barack Obama’s health care law.

Trump’s haphazard approach to the health care bill — first demanding a House vote despite an uncertain result, then suddenly suggesting he’d support a future bipartisan solution — underscored Trump’s political identity: He is seemingly uninterested in leading a political party or unifying the federal government.

The failed vote — despite Republican control of the White House and both houses of Congress — highlighted severe cracks within the GOP that Trump’s presidency won’t easily mend.

Trump now wants to turn to tax reform, an ambitious, complicated plan at the center of his agenda, and he does so wounded by the health care collapse as well as the uncertain legal status of his travel ban and an ongoing federal investigation into possible contacts and coordination between his campaign aides and Russian officials.

The loss exposed a limit to Trump’s go-it-alone style, one forged over decades in the business world and seemingly proven effective by his improbable win.

The novice campaigner used the sheer force of his celebrity and personality to draw loyal supporters and frequently bend the Republican Party to his whims.

He defied the party leadership repeatedly, skipped a debate, refused to sign a loyalty pledge and turned the scathing power of his Twitter account on fellow Republicans even after he clinched the nomination and the party pined for unity.

Experts say Trump’s style has hurt his ability to govern effectively.

“Donald Trump’s ‘Art of the Deal’ doesn’t work in Washington. Politics is a profession and you have to know how to collect votes,” said Douglas Brinkley, a presidential historian at Rice University. “Trump is a salesperson and he oversold what he can get done.”

Brinkley said Trump’s failure stood in stark contrast to the master negotiations conducted by presidents Franklin D. Roosevelt and Lyndon Johnson, who enjoyed majorities in both houses of Congress and achieved sweeping legislative accomplishments.

Instead, Trump’s initial struggles were reminiscent of the problems Jimmy Carter faced when he declared that his fellow Democrats were “an albatross around my neck” while facing intraparty rebellion.

More than two dozen members of the House Freedom Caucus oppose the health care plan because they say it doesn’t go far enough to undo Obamacare.

Some moderate Republicans, meanwhile, were turned off by a recent Congressional Budget Office analysis predicting 24 million people would lose coverage in a decade.

Republicans seemed willing to risk Trump’s wrath, taking comfort in the political safety their deep-red home districts provide against his possible attacks.

Trump was once a Democrat. He favored abortion rights most of his adult life and espoused views on trade similar to those of liberal Democratic presidential candidate Bernie Sanders.

He often doesn’t work in specifics, allowing supporters to read in what they want and he abruptly shifts stances — like when he abandoned his vow to send Hillary Clinton to prison — yet rarely losing support of his loyal backers. That degree of unpredictability gave some credibility to his ultimatum to force a vote or keep Obamacare in place, despite his years-long crusade against it.

Trump’s commitment to the bill seemed wavering. He said “there were things in this bill that I didn’t particularly like” and, for the first time, suggested that he would support a bipartisan health care measure.

He also claimed that “I’ve never said repeal and replace Obamacare within 64 days,” a surprising statement considering he vowed to do so “on day one” nearly every night on the campaign trail.

Though Trump publicly abstained from blaming House Speaker Paul Ryan, the White House suggested some fault lay with members who opposed the measure. That act of political defiance should seem familiar to the occupant of the White House, according to one longtime Trump ally.

“The people who are defeating this are the ones most like Trump — ones willing to break from the pack,” said former House Speaker Newt Gingrich, who also questioned the wisdom of setting a hard deadline to pass the legislation.

“If it was a negotiating tactic, it wasn’t a good one,” said Gingrich, who suggested that relations between Trump and Ryan, always strained, would get worse.

“The president feels burned. I suspect you’ll see him far more engaged on matters like tax reform, which he is passionate about. But it will be more complicated now.”

Republican leaders’ failure to get the health plan through the House, a task considered easier than in the Senate, may portend even greater difficulty in passing complicated tax reform and the rest of Trump’s ambitious agenda.

“Doing big things is hard,” said Ryan.

No vote on health care: A humiliating defeat for Trump

In a humiliating failure, President Donald Trump and GOP leaders yanked their bill to repeal “Obamacare” off the House floor when it became clear it would fail badly — after seven years of nonstop railing against the health care law.

Democrats said Americans can “breathe a sigh of relief.”

Trump said Obama’s law was imploding “and soon will explode.”

Thwarted by two factions of fellow Republicans, from the center and far right, House Speaker Paul Ryan said President Barack Obama’s health care law, the GOP’s No. 1 target in the new Trump administration, would remain in place “for the foreseeable future.”

It was a stunning defeat for the new president after he had demanded House Republicans delay no longer and vote on the legislation, pass or fail.

His gamble failed.

Instead Trump, who campaigned as a master deal-maker and claimed that he alone could fix the nation’s health care system, saw his ultimatum rejected by Republican lawmakers who made clear they answer to their own voters, not to the president.

He had“never said repeal and replace it in 64 days,” a dejected but still combative Trump said at the White House.

However, he had repeatedly shouted during the presidential campaign that it was going down “immediately.”

The bill was withdrawn just minutes before the House vote was to occur and lawmakers said there were no plans to revisit the issue.

Republicans will try to move ahead on other agenda items, including overhauling the tax code, though the failure on the health bill can only make whatever comes next immeasurably harder.

Trump pinned the blame on Democrats.

“With no Democrat support we couldn’t quite get there,” he told reporters in the Oval Office. “We learned about loyalty, we learned a lot about the vote-getting process.”

The Affordable Care Act was approved in 2010 with no Republican votes.

Despite reports of backbiting from administration officials toward Ryan, Trump said: “I like Speaker Ryan. … I think Paul really worked hard.”

For his part, Ryan told reporters: “We came really close … but we came up short. … This is a disappointing day for us.”

But when asked how Republicans could face voters after their failure to make good on years of promises, Ryan quietly said: “It’s a really good question. I wish I had a better answer for you.”

Last fall, Republicans used the issue to gain and keep control of the White House, Senate and House. During the previous years, they had cast dozens of votes to repeal Obama’s law in full or in part, but when they finally got the chance to pass a repeal version that actually had a chance to become law, they couldn’t deliver.

Democrats could hardly contain their satisfaction.

The outcome leaves both Ryan and Trump weakened politically.

For the president, this piles a big early congressional defeat onto the continuing inquiries into his presidential campaign’s Russia connections and his unfounded wiretapping allegations against Obama.

Ryan was not able to corral the House Freedom Caucus, the restive band of conservatives that ousted the previous speaker. Those Republicans wanted the bill to go much further, while some GOP moderates felt it went too far.

Instead of picking up support, the bill went the other direction, with several key lawmakers coming out in opposition. Rep. Rodney Frelinghuysen of New Jersey, chairman of a major committee, Appropriations, said the bill would raise costs unacceptably on his constituents.

The defections raised the possibility that the bill would not only lose on the floor, but lose big.

The GOP bill would have eliminated the Obama statute’s unpopular fines on people who do not obtain coverage and would also have removed the often-generous subsidies for those who purchase insurance.

Republican tax credits would have been based on age, not income like Obama’s, and the tax boosts Obama imposed on higher-earning people and health care companies would have been repealed. The bill would have ended Obama’s Medicaid expansion and trimmed future federal financing for the federal-state program, letting states impose work requirements on some of the 70 million beneficiaries.

The nonpartisan Congressional Budget Office said the Republican bill would have resulted in 24 million additional uninsured people in a decade and lead to higher out-of-pocket medical costs for many lower-income and people just shy of age 65 when they would become eligible for Medicare. The bill would have blocked federal payments for a year to Planned Parenthood.

Republicans had never built a constituency for the legislation, and in the end the nearly uniform opposition from hospitals, doctors, nurses, the AARP, consumer groups and others weighed heavily with many members. On the other side, conservative groups including the Koch outfit argued the legislation did not go far enough in uprooting Obamacare.

Ryan made his announcement to lawmakers at a very brief meeting, where he was greeted by a standing ovation in recognition of the support he still enjoys from many lawmakers.

When the gathering broke up, Rep. Greg Walden of Oregon, chairman of the Energy and Commerce Committee that helped write the bill, told reporters: “”We gave it our best shot. That’s it. It’s done. D-O-N-E done. This bill is dead.”