SOMEWHERE along the line, the health care debate stopped being about health care and devolved into how we are getting used to seeing the Trump administration do business. Threats to fire people or, if they’re in Congress, to work against them. So with any pretence gone, President Trump’s point person on health care, Health and Human Services Secretary Tom Price, described the administration’s new goal as “what gets us 50 votes so we can move forward.” Not a law which covers more people? Or reduces the cost of care? Or protects American families from bankruptcies? When I served in the Obama administration, we dealt with hard issues and didn’t always get them right, but we never lost sight of who we were serving – working families, kids, seniors, people with disabilities, people plotting their retirements with modest incomes – and often at their most vulnerable moments. In these last six months, the country has been introduced to the Little Lobbyists, parents and kids with complicated illnesses, who have come to the Capitol urging that hundreds of billions of dollars not be cut from the Medicaid program. I’ve gotten to know Laura Packard, a self-employed young woman with Stage 4 cancer who lives in Nevada, whose doctors believe she can beat her cancer if she can keep up her treatments, which are dependent on her plan from the ACA. Yet for Price, repealing the ACA is personal in a different way. As with Attorney General Jeff Sessions, Price was warned by a grinning Trump during a public speech that his job was on the line if the bill didn’t pass. As amusing as that may have been, the message was crystal clear. Fifty votes, any way you can get them, and Vice President Pence will break the tie. In other words, the already fragile premises of repealing and replacing the ACA have been officially shattered. The premise that a bill was needed to save the ACA by increasing stability. The “skinny bill” the Senate now aims to pass would quickly hasten a death spiral by removing the coverage mandates that spread risk among the healthy and the sick. The premise that Trump won’t accept a “mean” bill, as he once called the House bill. The Senate is committing to an “unconditional surrender of Senate GOP to the House bill” in the words of Senator Chris Murphy, D-Conn., if they pass a “skinny bill” and go into negotiations with the House in a conference committee. The premise that there is a maverick out there who is ready to put the impact on the American public or a well-functioning Senate over party politics. Arizona Sen. John McCain returned to the floor from surgery on a brain tumour to lecture the Senate about voting for what he vividly described in unflattering terms. Only to vote for it right afterwards. With these premises shattered, as shallow as they once were, one-sixth of the economy and the lives of people like Laura are now tied up in pure win-or-lose politics. Tom Price’s job, McConnell’s reputation as a leader, allegiance to a stale campaign promise. The “skinny bill” would raise premiums by 20% while causing 16 million fewer people to have coverage next year, according to the nonpartisan Congressional Budget Office. The House bill is even worse. The CBO estimates it would cost 23 million Americans their health insurance by 2026 and cause premiums to rise 20% next year, while dramatically cutting Medicaid and ending federal insurance protections for people with pre-existing conditions. Many Americans who are low-income, older or living in rural communities would no longer be able to afford insurance – while the savings from the bill would be applied to tax cuts for the wealthy. The president called it a mean bill for a reason. And it is not dead. It or a close relative could rise again in a House-Senate conference committee. Then it would go to both chambers for a simple up-or-down vote after very limited debate, and no ability to change it. GOP Sens. Susan Collins of Maine and Lisa Murkowski of Alaska, by voting this week against proceeding with any bill, have said enough is enough. All they ask is a return to regular order – public hearings and committee work sessions followed by debate, amendments and votes on the Senate floor. If you’re like me and you still put some stock in the institutions of our democracy, including the reasoned, considered processes of the Senate, the last bit of your faith may be in the hands of one more senator willing to see the Senate as a final check on the president’s tear-it-all-down approach. Published in Daily Times, July 30th , 2017.