PROVIDENCE – The afternoon of May 30 at the State House was filled with numerous distractions, at least in terms of the news media.

R.I. House Speaker Nicholas Mattiello was set to meet the press and unveil his plans to phase out the state’s car tax over the next six years, in order to serve the people’s agenda, whatever that means, which sucked all the proverbial air out of the building.

Rhode Island Housing was holding a meet-and-greet reception in the State House Library to promote housing as an economic development strategy, featuring two legislators from Massachusetts, Sen. Jamie Eldridge and Sen. Joseph Boncore, chair of the Joint Committee on Housing, to discuss the return-on-investment in developing affordable housing.

So, there was a modest but influential audience that attended the policy briefing by Sen. Sheldon Whitehouse, hosted by the R.I. Senate Democratic Policy Caucus, about the ongoing efforts to repeal the Affordable Care Act and the implications for Rhode Island. But only ConvergenceRI and one other media outlet were there to cover the event.

Dead, dead, dead
Whitehouse declared that, in his opinion, the House version of the American Health Care Act, also known as Trumpcare, was dead on arrival in the U.S. Senate.

“The House bill is dead; dead, dead, dead,” said Whitehouse, to a round of applause, in response to a question from a state senator about whether there was any hope that the Affordable Care Act would not be repealed.

The big question before Senate Majority Leader Mitch McConnell, according to Whitehouse, is what path he will take moving forward. McConnell’s choices are to try and ram through a revised Senate version of the House bill, to make the bill fit within the reconciliation rules, with 50 votes, or to choose to create a bipartisan bill, following parliamentary rules that requires 60 votes.

The risk to McConnell, according to Whitehouse, is that the Senate is stuck with what he termed “a collision with the facts” about what is actually in the bill, and the political reality on the ground, which is that “they don’t know whether they are winning or losing” in advance of the 2018 and 2020 elections.

“It puts them in a bit of pickle,” Whitehouse said.

Decision before the recess in July
The members of what Whitehouse described as “the 13 white man [Republican] study group” in the Senate have been told to shut up, not to reveal anything that is being discussed, according to Whitehouse.

At the same time, the Democratic caucus in the Senate has been able to maintain its own discipline among its ranks, according to Whitehouse.

The Democrats who in are in conversations with their Republican colleagues, Whitehouse said, “To a person, they are saying to Republicans, ‘We are a committed caucus on this, and we can talk, but you are not going to shave away a few Democrats on this to get the bill passed.’”

In terms of strategy, Whitehouse continued, the Democrats are “holding our powder.” Time, he said, “is not our enemy as much as theirs.”

If and when McConnell decides to follow the regular parliamentary order of the Senate, Whitehouse explained, the Democrats will be ready to roll out an alternative plan and begin seeking Republican support for their ideas.

A decision by McConnell will probably be made, Whitehouse predicted, before the summer recess.

From a political standpoint, Whitehouse continued, “It will be hard to leave all the [Republican Senators] hanging over that six- to seven-week period, with no decision made on this.”

What might be in an alternative Democratic bill
One of the ideas that might become part of an alternative Democratic version of a health care bill is a public option, creating a Medicare-for-all plan, with the potential to lower the age of eligibility from 65 years of age to 60, or even 55, according to Whitehouse.

That idea of creating a public option, being promoted by many in the more progressive wing of the Democratic Party, has apparently developed some traction in recent weeks.

The public option, described as a Medicare-for-all plan, would be a welcome idea in areas of the country where the exchanges are failing, according to Whitehouse. It would operate as a separate insurance plan, according to Whitehouse.

“When you drop the eligibility from 65 to 60 or 55 years,” he continued, “you make a lot of people happy.” From the commercial insurance marketplace perspective, Whitehouse continued, it would pull many of the “more expensive” patients out of the competitive system.

[In California, on June 1, the State Senate approved a preliminary plan for enacting a single-payer system. In Rhode Island, a Medicare-for-all bill sponsored by Rep. Aaron Regunberg had its legislative House Finance Committee legislative hearing on May 24.]

Rhode Island as an innovative leader
Whitehouse said that many of the innovative ideas now in practice in Rhode Island might also find resonance within an alternative Democratic health care bill, including: the focus on cutting medical costs through an emphasis on primary care, as implemented by Coastal Medical and the Rhode Island Primary Care Physicians; the initiative to reduce hospital acquired infections, what Whitehouse said “remains a plague throughout the health care system”; and more emphasis on having patient-directed conversations about end of life care.

[What Whitehouse did not talk about was innovations in health care delivery being developed as community-driven initiatives to address disparities: health equity zones in 10 Rhode Island communities; neighborhood health stations in Central Falls and Scituate; and the use of affordable, healthy housing as a prescriptive measure to improve outcomes.]

State vs. federal protections
Sen. Joshua Miller, chair of the R.I. Senate Committee on Health and Human Services, asked Whitehouse about efforts underway in Rhode Island to protect and preserve essential benefits, and whether it could prove to be a beneficial strategy for other states to follow.

Whitehouse offered praise for the effort, particularly around protecting maternal health benefits, but cautioned that it could lead to unintended consequences of the federal government saying, OK, the states have that responsibility, so that they can then cut the strings.

Miller also asked about the idea that selling health insurance across state lines could provide some cost relief in terms of insurance premium costs.

Whitehouse challenged the idea, saying health insurance, was different from other kinds of insurance products in the marketplace. Unlike the idea that if a rock falls on your house and the only obligation is to make sure that the check is sent, with health insurance, you need to have a network, you need a primary care provider, you need a computer system in place with electronic health records.

“You can’t just mail it in from Arkansas,” Whitehouse said. “Real health insurance requires a real network of health doctors.”

The crisis in rural America
Whitehouse also addressed what he termed the crisis in rural America where many of the hospitals are beginning conversations with bankruptcy lawyers because of the expected rollbacks in Medicaid coverage under President Trump.

Under the Affordable Care Act, Whitehouse explained, hospitals in rural areas have been supported, getting paid for providing care that once went into the uncompensated care bucket. “When you start to pull down Medicaid,” he said, to pull down some $1.4 trillion over 10 years, “I don’t think that states are going to be able [to make up that] $1.4 trillion.”

As a result, hospitals are looking at the potential for costs of uncompensated care going through the roof, Whitehouse said. “That is part of the reasons why there is such blowback against this bill.”

Medicaid, Whitehouse continued, is often misunderstood. “Many thought it was basically an urban support program. What they don’t know is that 60 percent of nursing homes payments in this country come from Medicaid.”

There is a lot of anxiety about the proposed cuts in Medicaid, Whitehouse said, “Where governors are starting to holler: ‘Wait a minute; I’m going to run a deficit just because you guys are making a mess of it?’ ”