The blurry outlines of an Obamacare overhaul are slowly coming into focus as Senate Republican leaders prod their members toward a health-care vote next week.
But the picture is fluid. And Democrats are blasting off fireworks in the background ahead of Senate Majority Leader Mitch McConnell's July 4th deadline.
McConnell, R-Ky., is holding his plan unusually close to the vest, even for him. While leaks are common for bills of this magnitude, lawmakers and aides are being guarded in what they disclose and few of the finer details have trickled across town to K Street.
We do know this: There will likely be legislation for Republicans to view this week. Much of its largest outlines will mimic the House version passed in May. Parts of it will be different. It’s almost certain to result in millions fewer Americans having insurance. It will also enact big savings for Medicaid. Here’s what we know so far – and what we don't – about the emerging bill:
1. The bill’s 50-vote pathway to passage is most likely to circumvent Sens. Susan Collins (R-Maine) and Rand Paul (R-Ky.), the two senators at each end of their party’s spectrum. Collins, a moderate, was the only Republican currently in Congress to vote against an Obamacare repeal bill in 2015, and the libertarian-minded Paul was the only one in his party to oppose a budget resolution earlier this year kicking off the whole process.
If that’s the case, McConnell will have to get every single other Republican on board in the closely divided Senate (and that's counting on Vice President Pence as a tie-breaker) – including Sen. Lisa Murkowski (R-Alaska), who has lately been displaying her displeasureat how the whole health-care effort is unfolding.
2. The Senate measure seems poised to enact deeper Medicaid cuts than the House bill. The Senate bill is shaping up not only to convert Medicaid to a leaner per-capita funding system, but also tie its growth rate to an even slower-growing index than under the House version (the Consumer Price Index for urban consumers, instead of what's known as CPI-Medical). Conservative senators, most prominently Sen. Patrick J. Toomey (R-Pa.), love this idea.
3. The Senate legislation is likely to gradually phase down the Affordable Care Act’s higher federal payments for the expanded Medicaid population. The phase down could take three years, or maybe longer. This would be a concession to moderates who don’t want to look like they’re pushing people off Medicaid too abruptly.
4. The measure seems ready to repeal or delay some or all of the ACA’s taxes. The levies that might be repealed include the ACA's health-insurance tax and a tax on medical devices -- two revenue streams the industry has vigorously lobbied to eliminate. But lawmakers have yet to make a final decision on that front. Much of the final verdict will have to do with how much funding they need to free up in order to pay for the bill’s ultimate benefits.
5. The Senate bill is likely to include a more generous version of insurance subsidies, tying them not just to age as in the House bill, but also to income.
6. The measure will likely exclude language banning federally subsidized health plans from covering abortions. The Senate parliamentarian has yet to make a final decision on whether such language is allowed under budget reconciliation rules. But from what we're hearing, even antiabortion advocates for such a ban acknowledge it's not likely to pass muster under the so-called "Byrd rules" governing what can go in the Senate bill.
Here's something else we know: Democrats are doing all they can to get in the way. They ultimately can't block Republicans from passing a health-care bill, since all the GOP needs is a simple majority using budget rules.
But last night Senate Democrats launched a series of mostly symbolic moves, including speeches that went late into the night and slowed down other Senate business, the Washington Post's Sean Sullivan reports:
"The aim, Democrats said, was to draw attention to the secretive process Republican leaders are using to craft their bill and argue that the GOP proposals would hurt Americans," Sean writes. "The Democrats lack the power to prevent a vote and they don't have the numbers to defeat a bill without Republican defections. So they are focusing this week on nonbinding protests."
At one point Monday night, more than a dozen Democratic senators sat at their desks on the Senate floor and took turns standing and asking for committee hearings on the as-of-yet unreleased measure and for the text to be released for greater public scrutiny, Sean reports.
Each time, McConnell -- who is the one spearheading his party's strategy -- calmly rose from his desk at the front of the chamber and objected to their requests.
"This is going to be a long evening because there are a lot of folks who are frustrated," Sen. Cory Booker, D-N.J., said at one point.
It's going to be a long two weeks, too.
Democrats shared a sign of a closed door with the words, "No hearing, no bill."
A number of Democratic members used the Twitter hashtag #HoldTheFloor.
Georgia's special election could effect health care legislation
Tuesday's special election for the seat of former Georgia Rep. Tom Price, a Republican who's now leading the Department of Health and Human Services, has turned into a referendum on President Donald Trump's leadership and could significantly alter the debate over health care in Congress.
If Republican Karen Handel wins, Republicans in Washington will likely feel emboldened to push ahead with their plans for a Senate vote before going home for the July 4th recess. But if Democrat Jon Ossoff prevails, all bets are off -- Republicans who are on the fence about supporting such controversial legislation might get cold feet and the party's leadership could entirely reassess (remember former Sen. Scott Brown's January 2010 special election victory and its effects on the ACA vote?).
The president acknowledged the high stakes in a tweet early this morning:
"KAREN HANDEL FOR CONGRESS. She will fight for lower taxes, great healthcare strong security-a hard worker who will never give up! VOTE TODAY," he posted.
"A Democratic victory in this traditionally conservative and wealthy swath of suburbia would probably rattle Senate Republicans as they try to jump-start legislation to overhaul the nation's health-care law by the end of this month," the Post's Paul Kane, Robert Costa and Karen Tumulty write. "And it would raise questions about whether Trump has retained a strong hold on his party's base as he turns to other policy ambitions this summer."
And the Post's James Hohmann visited the district and discovered that many Republicans and independents may not like the House bill but detest Obamacare and are willing to give Trump a chance to fix the system.
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The health-care industry has often appeared declawed as Republicans push a sweeping and unpopular Obamacare overhaul through Congress -- even though it once cut deals back in 2009 to shape the ACA and helped kill Hillarycare in the 1990's, Vox's Dylan Scott reported.
"It's a deliberate strategy, interviews with nearly 20 lobbyists and other experts suggest," Dylan writes. "Health industry groups generally don't loveObamacare enough to jeopardize thei r ability to shape the rest of the Republican agenda - including big corporate tax cuts. They also fear incurring White House retaliation."
"Further complicating matters, different sectors within the industry have very different stakes in repealing Obamacare and replacing it with the GOP's plan," he continues. "Many health insurers are already ambivalent about Obamacare and could see significant tax cuts if the law is rolled back. Doctors and hospitals, on the other hand, could face a surge in uninsured patients if millions fewer Americans have health coverage.... As a result, those groups have not collectively gone all out, on the airwaves or in the halls of Congress, to stop the GOP's health care bill - even though they have expressed almost unanimous opposition to it."
More and more in the Trump era, business in Washington is happening behind closed doors, the Post's Philip Rucker and Ed O'Keefe report. "The federal government's leaders are hiding from public scrutiny - and their penchant for secrecy represents a stark departure from the campaign promises of Trump and his fellow Republicans to usher in newfound transparency," they write.
Examples: Agency officials have withheld internal documents from even friendly Republicans, Trump is forbidding the release of his tax returns, the White House is refusing to release visitor logs and media aides have started banning cameras at otherwise routine news briefings. Oh, and then there's the health-care bill being written without any public hearings.
The Obamacare overhaul situation is in the hands of Senate Republicans at the moment. But it's still important to pay attention to what House Republicans say about it because the House will have to put a stamp of approval on whatever a final bill looks like, if it's ever going to Trump's desk.
All signs in the Senate bill point to a longer phaseout for the ACA's Medicaid expansion. A group of House conservatives is trying to tug the bill in the opposite direction. The Republican Study Committee laid out four demands in a letter it's planning to send to McConnell later this week. Their asks include:
1. Clamping down on Medicaid expansion more quickly and in 2020 completely cutting off the extra federal dollars for enrollees.
2. Allowing states to opt out of the ban against charging more to those with preexisting conditions and essential health benefits.
3. Repealing all of the ACA taxes.
4. Defunding Planned Parenthood for one year and banning federally subsidized plans from covering abortions.
The Post's Glenn Kessler dug into this comment last week from House Minority Leader Nancy Pelosi:
Pelosi:"Americans will lose their health coverage because of his proposal. And it is a job loser. Estimated to be 1.8 million jobs lost. Donald Trump is a job loser."
The facts: Pelosi was relying on a March report by the left-leaning Center for American Progress, adapting an earlier study by experts at George Washington University on the impact of full repeal of Obamacare. That study found that full repeal would lead to a loss of almost 3 million jobs by 2021.
"But here's the rub," Kessler wrote. "The George Washington University experts whose research was the basis for the CAP report did their own study on the AHCA, which was published in June. They estimated a loss of 413,000 jobs by 2022, less than one-quarter of the two other estimates...Moreover, the researchers said that the repeal of tax cuts in the law would help to initially increase the number of jobs by 864,000 in 2018."
"The nuances and caveats are often lost when the figures are used in political discourse," he wrote. "As we have shown, the overheated claims of job losses and job gains stemming from Obamacare turned out to be false. The impact appears to have been more muted than what either side had predicted...Given the range of outcomes, Pelosi should be more careful about citing such a precise figure. She earns two Pinocchios."
Now just one county in Washington state lacks a 2018 Obamacare insurer, instead of two. As he'd indicated last week, insurance commissioner Mike Kreidler announced Monday that Premera Blue Cross will sell two marketplace plans in Grays Harbor County next year. Kreidler also expressed hope he'll be able to entice an insurer into Klickitat County too.
"My office is doing all it can to get this concern resolved as quickly as possible," Kreidler said, in a statement. "I remain optimistic that my discussions with insurers will prove successful for Klickitat County."
Washington is one of several states where some residents may have no marketplace options next year -- although its problems are less pronounced than in states like Iowa and Ohio, where large regions could be without an Obamacare insurer.
How did Alaska keep its marketplace rates in check, at a time when nearly every state was seeing their Obamacare plan prices jump, some by 20, 30, even 50 percent? Roll Call's Erin Mershon explained in a dispatch from Juneau, where she talked to the state's insurance commissioner, Lori Wing-Heier, about the smashingly successful reinsurance program she set up to help protect insurers against losses.
"It seems like a simple solution based on the concept of reinsurance, transferring a portion of risk to another entity," Erin writes. "The program really did reduce consumers' expected premiums, which are at the center of so many complaints over the health law. The idea isn't nakedly partisan, like so many other health proposals, and doesn't alienate the hospitals, doctors or insurance companies that often fight changes to their business models."
"The Obama administration openly praised her plan, a surprise for a red state. Then the incoming Trump transition team did, too - a rare area of bipartisan agreement on not just health care policy, but on the controversial law known as Obamacare, the Affordable Care Act," Erin writes. "Policy experts, too, have lauded Alaska as the first state to "fix" the health care law...Commissioners across the country asked for the details of her success. Minnesota and Idaho set up similar programs, and policymakers in Maine introduced legislation modeled on the idea. Other states like California, New Hampshire, Ohio and Oklahoma are eyeing the program for 2019 and later."