JournalistI'm Dan Diamond, a POLITICO reporter tracking the health care fight. AMA away.

Mar 24th 2017 by DDpolitico • 18 Questions • 962 Points

Hey redditors! I'm Dan Diamond, the author of POLITICO's daily health care column and host of our weekly health policy and politics podcast. And I'm at the Capitol today, covering the health care debate.

Things are moving quickly on Republicans' plan to change the health system, and many readers have told me they're nervous about what it means for them. I've also interviewed congressmen, had extensive conversations with current and former White House officials, and sat down with experts and patients around the country.

I'm happy to take questions on anything — but I'm especially ready to talk the state of play for the GOP health bill, myths vs. facts on the ACA, and bigger issues for the U.S. health care system.

Update: I've been AMAing with one eye and working with the other, but given the breaking news, I need both at this point! Thanks so much for making this so interesting. And the r/politics folks invited me to do an AMA next Friday 3/31, and I'm looking forward to coming back.


If the AHCA is passed as currently drafted, who is the biggest winner and who is the biggest loser?

(For bonus points, same question if bill is brought to a vote and not passed.)


So many ways to answer this question!

Republicans, in some ways, could be short-term winners and long-term losers. They get the credit for passing a bill ... that will reduce coverage for lots of people and shake up the insurance market yet again. So they could get punished in upcoming elections.

But the insurance industry and certain businesses (i.e., restaurants) are probably best positioned to be the winners — the AHCA relaxes taxes and regulations that they hate.

Loser: Poor, unhealthy Americans who depend on various Affordable Care Act expansions and protections.


What are the political implications of this bill either failing of passing in the House? To what extent will this hurt President Trump, or confirm his status as the leader of the Republican party?

Bonus question: if this vote fails, will Ryan still be Speaker?


One of the big questions of the day around the Capitol... here's one way to think about implications of failure.

Meet a president who failed to pass health reform in his first year, despite big talk: Bill Clinton. He went on to serve two terms and strike tons of deals with the Republicans.

Meet a president who kept asking Congress to do health reform, but they wouldn't agree to his timeline: Barack Obama. Not only did he eventually get it done, ditto on the two terms yadda yadda

Now if the bill somehow passes in current form, we're in a new ballgame where the Senate parliamentarian will determine if the bill can even comply with budget reconciliation rules. Given state of play today, not sure it's worth going into political implications on that yet.

Re the bonus Q — NO IDEA. But the conservatives — who made the most trouble for Boehner, and are now agitating against AHCA — may be happy if Ryan finds a way to spin a dead bill as respecting their wishes.


How much money are healthcare industry lobbyists currently spending to influence the outcome?


Great question. There’s no reliable roll-up number, but certainly in the tens of millions and probably more than $100 million. Advocacy groups are doing everything from buying ads on “Morning Joe” and “Saturday Night Live” to sending direct mail and holding rallies.

At the same time, there’s a lot more money being spent on non-Affordable Care Act issues, which makes sense — the ACA is just one corner of health care. The pharmaceutical industry recently launched a gigantic campaign to try and repair their reputation (and hold off pressure on drug prices).


I think it would be a great benefit to everyone, public and those involved in the process and even the media as a whole, if the media stopped ignoring, or not talking specifically about, how much lobbying money is invested into the processes that govern this country.

What I mean is; every story about major issues should include a section that talks, in specifics, about how much money is being injected into the process. When various special interests open their checkbooks, media should track that money as best they can and talk about it. In detail. Not generalities.

"The X, Y, and Z special interests have been heavily opposing this bill..." is forgettable. "X, Y, and Z have spent tens of millions of dollars in the last ten days hosting fundraisers, buying advertising, making donations, etc... to oppose this issue" is specific and makes people specifically think about how their voice is being overridden by money.

"Everyone knows" special interests put their fingers on the scale. That's a generality. The media should make it a specific issue, and attach it to every story. Stop letting the interests hide in the background noise and call them out, constantly. If nothing else, it might make them divert some of their scale altering funds into protecting their own images.

Now, obviously I know the interests don't copy their expenditures to you or anyone else. But you can make estimates. Public records, campaign donations, hotel and catering expenses, how many ads in which markets/time slots at how much average cost, etc... Yes it requires some work. But media is supposed to be doing that kind of work, tracking information and sorting it for the public.


You're absolutely right on the value — and need — for transparency.

POLITICO's pretty good at this:

  • We have a dedicated team on the lobbying beat; here's their morning newsletter

  • My colleagues and I break a lot of health care-specific news in our own morning newsletters about advocacy groups' spending.

  • And when we write a relevant feature, we always try and include context on why a group is supporting or opposing and when $$ are in play

I wish we had some ongoing, interactive database, though. That's a great idea.


Why all the brinkmanship right now?

With Senate passage looking increasingly unlikely (both for lack of vote count and by running afoul of reconciliation restrictions), the House 'victory' would be hollow at best. And even then, there's another 1 1/2 years before the midterms to hammer out more details and do some deal-making, maybe even (gasp!) across the aisle. Instead, it feels like everyone's painted themselves in a corner.


The brinkmanship is because of one person: Trump.

He's pulling power moves straight out of "The Art of the Deal." Those moves may work on Wall Street; the U.S. Congress is really, really, REALLY not designed for "take it, or leave it" deals that are dropped on them like this — especially when the bill has this much impact.


Thanks. I hadn't realized how heavy a hand he had in establishing the speed of the legislation, as well as the current now-or-never approach.

It felt like he had 'outsourced' the healthcare plan to Ryan and was only coming in to make sure that he 'wins' with something getting passed.


You're right — the bill's language is being driven by Ryan. But the "take it or leave it" approach today is all Trump. Ryan doesn't want to get embarrassed on the floor.


Honest question: Does Trump understand that legislation needs to pass both the House and the Senate?


Ha! The DC joke is that he doesn't know what's in the bill, but yes, he gets the process.

What Trump may be fully realizing is that he's not the CEO of America — Congress is its own branch, with its own workings, and they can push back. Like the House GOP is doing right now.


I don't know if you're in a position to comment on the media side of things, but a quick look at Brietbart will tell you that over the last few days, stories increasingly critical of the bill have been on its frontpage. Do you think this indicates some type of pivot meaning that the "Trump wing" doesn't think this thing is going to pass and wants to preemptively do a sour grapes kinda thing/distance themselves from it? Or do you think there's no particular insight to be gleaned from the observation?


It's a good observation.

I read Breitbart every day now — which isn't something I would've said a few weeks ago — and it's amazing how critical the site has been of Republicans' health plan and specifically Paul Ryan's role.

I don't think it's been a recent pivot because the bill's odds have plunged, though. They've hated the bill since it was first being drafted, because in the eyes of Breitbart (and conservatives) it doesn't do enough to repeal the ACA right away. And Breitbart has always looked for ways to zing Ryan, who they don't trust.


In what ways do you read Breitbart and what recommendations about it would you give to others? I understand the need for differing perspectives to get a fuller picture, but is Breitbart the answer for the everyday person or are there better options?


I read them for a few reasons.

1) To see a conservative reaction to the news 2) To see their specific scoops — i.e., Rand Paul gave them a newsy interview where he said Paul Ryan was trying to "pull the wool over the eyes" of Trump on this health bill

I can't comment on all of Breitbart — I'm usually just parachuting in quickly to read their health care coverage.

But given all of the criticism I'd heard, one thing that's surprised me is that small details of their health care policy and politics coverage aren't so different from what you might read in the Associated Press. Senator X said this thing, Governor Y said another — they report a lot of things that are factually true.

The big difference is how they spin and frame the news. Their headlines can be especially provocative. That's not so dissimilar from their liberal counterparts, I think.

So if your media diet is overwhelmingly left-leaning news, I do think reading Breitbart can be a useful corrective. Also, their site is much cleaner and easier to use than some of their competitors.


Dan what is your daily routine? You seemingly never sleep.


It varies by the day, but there are a few constants.

  • My number one job is to write the daily PULSE newsletter, which comes out at 5:45 a.m. For everyone's sanity, I usually start collecting "string" (a newsroom term for notes, quotes, thoughts, etc.) the afternoon before and try to have PULSE mostly done by 9 p.m. that night. I then dip back in around midnight to make sure nothing's missing.

  • For the weekly podcast, there’s an ongoing mix of scheduling with guests, doing as much prep as possible, conducting the interview, and then helping produce it.

  • I also do other things for POLITICO — like write feature stories and quick hits or moderate panels — and try and work those in when possible.

  • I probably spend too much time on Twitter. But I learn so much and have so much fun doing it.


What I can't get in the whole discussion is who is checking on the health insurance prices? The same insurance offers less benefits with higher deductibles for ACA versus employer plans. Is there proof that the ACA insured are more sick than the others? and why in heaven prices went up in certain states and not in others? are those states much more sick?


There've been various reports that found the patient mix of people buying ACA plans is sicker than expected.

The reason why insurance premiums go up at different rates in different states is all about local market dynamics and political decisions. If there are more insurers in a given market, that can sometimes drive the price of premiums lower through competition. If there's a market like Alaska or Wyoming, where there aren't that many doctors around, the prices might be high for reasons that have little to do with the ACA.

And if governors decided not to expand Medicaid or fight the ACA, that can be a factor in driving up prices too. Link


Does anyone ever try to tell the politicians voting for this bill the lives that will be lost by approving it? You mentioned in another question that those voting for it see it from the view of politics rather than the people, but has anybody ever confronted those politicians when they say something like that?


He's not a politician, but you can hear what happens when I asked the CEO of FreedomWorks — the influential conservative advocacy group, which wants to fully repeal the Affordable Care Act — what happens if one American dies as a result. Skip to 55:45.


I get what you're saying, that the CEO doesn't really want to address that question and deflects to saying how, because our health care plan will be better, one life wont matter, without saying that of course. But what I'm getting at, and something that I'm becoming a journalist because of, is that it should also be the job of the reporter to press guys like that into actually giving an answer, especially on a question like that. I mean isn't it the job of reporters and journalists to ask the hard questions and to push people into answering those questions?


P.S. One of my favorite days as a writer was covering the Supreme Court in the morning and the Wizards at night. Not as impressive as John Wall going coast-to-coast, but I can't think of too many reporters who get to pull off the court-to-court move.


who are the least well-known congressmen who hold more power than would be expected on this issue?


Depends on how you define "least well-known" — there are big names like Greg Walden (chairman of the Energy & Commerce Committee, who played a key role in drafting the bill) who aren't known nationally.

Usually, folks who are in leadership or chairing subcommittees are the ones to watch — they often get those positions because of the perceived ability to bring others along.

On health care specifically, folks like Michael Burgess and Phil Roe are outspoken and have played big roles.


Presuming we take Trump at his word and Congress passes the AHCA in some form or we're 'stuck' with ACA/ObamaCare, --should AHCA fail-- what tools are available to Congress/POTUS to do as much 'damage' as possible to ACA/ObamaCare to hasten its demise/unpalatableness without extraordinary legislative action? In other words, if ACHA fails what could be realistically accomplished through executive action, regulations, red tape, budgeting, et cetera that could damage the ACA/OCare/Exchanges and therefore healthcare access for millions of Americans?


WorldsOkayestDad, I can't imagine you're my dad, but thanks for asking a question that's perfectly timed for me.

I just wrote a big story for POLITICO yesterday on how the White House is already weakening the ACA and its exchanges. You can read that story here!


What is Trump's relationship with the Freedom Caucus and what role will the Caucus play in the Trump Administration?

Because of the Freedom Caucus's hardline brand of conservatism, does this put them in opposition to the Trump presidency? Will that mean they will play a bigger role in today's politics as "anti-Trump" Republicans, or can the House pass legislation without them altogether?


Your user name totally threw me for a moment. Is this answer going to be on air tomorrow???

No one knows what happens next. Freedom Caucus members have been key Trump allies for a long time — they seemed simpatico on some big conservative ideas. And as caucus chairman Mark Meadows noted, he was Trump's lone supporter in North Carolina for a while. Caucus co-founder Mick Mulvaney is Trump's budget director.

But if this bill dies because of the Freedom Caucus and Trump remains famously vindictive ... sheesh.

There are lots of ways the health bill, and the Trump presidency, could go. There's a world where he somehow works out a deal with the caucus on health care and tacks further to the right. There's also a world where Trump ends up closer to the middle, just for the sheer ability to get stuff done. Since there are only ~35 members of that caucus, and if you can get Dems or centrists on board, it's not impossible to get legislation through.



WAIT, do we yell that first or are we supposed to read something first? Stuff is hard!


You know, I interviewed Zeke Emanuel this week and even he yelled that at me first. I think that's just how you greet reporters in 2017.


Do they even care that they're killing people while arguing about re-electing Trump?


As a reporter, I can't comment on the (emotional) thrust of your question.

But I do have an observation, having talked to so many lawmakers, lobbyists and others in recent weeks.

And maybe I'm naive — but I'm shocked that so many of their comments focused on the optics and politics and ignored the patient impact.