What Went Down On Health Care This Week

At the risk of being slightly repetitive, we’re basically looking at four major possibilities at this point.

• Possibility 1: “Skinny repeal” doesn’t pass the Senate. Health care reform is dead, at least for the time being.
• Possibility 2: “Skinny repeal” passes the Senate, and the House also passes “skinny repeal.” “Skinny repeal” becomes law.
• Possibility 3: “Skinny repeal” passes the Senate, but the bill that emerges out of conference is an AHCA-type bill instead. Both chambers vote to approve the AHCA-type bill, which becomes law.
• Possibility 4: “Skinny repeal” passes the Senate, but the conference bill fails, either because the House and Senate can’t agree on a compromise or because an AHCA-type bill can’t pass the Senate.

Scenarios No. 2 and 4 are looking more likely than No. 1 and 3 at this very moment, but all four are live possibilities. And who knows if there are other potential solutions, such as if “skinny repeal” becomes a little fatter and transforms into “Dad Bod/Mom Bod repeal” as amendments are added during the vote-a-rama.

As we’ve noted at various points today, the GOP is reportedly getting ready to try to pass a “skinny” repeal of Obamacare. At the moment, that would mean effectively ending the individual mandate, in addition to ending the employer mandate and a tax on medical devices. Ending the individual mandate is a complicated matter. It’s one of the least popular aspects of the Affordable Care Act, but it’s also in theory what makes the law work: It requires most people to have insurance, which is supposed to help create a good mix of healthy and sick people in the insurance markets, which should in turn make insurance affordable. The provision has had mixed success. On the one hand, there’s been a serious lack of enrollment among people whose incomes are far above the federal poverty line, which has certainly contributed to higher premiums. On the other hand, the markets have largely stabilized. What that latter point means is that, even though the markets are not working for everyone, they are also not in a death spiral, as the president and Republicans have repeatedly said. That’s because low-income people whose incomes fall just above the poverty line receive significant financial help to buy insurance; whether or not premiums go up, they pay the same amount for insurance, and they have generally stayed enrolled. If you take away the individual mandate, those people will probably stay enrolled, meaning we still wouldn’t see a death spiral (though people currently enrolled on the marketplaces who receive few or no subsidies are likely to be priced out), so long as the Senate also keeps the subsidies that make insurance cheaper. That includes not only subsidies for premiums, but also “cost-sharing reductions” that help pay for co-payments and deductibles. It’s not clear how Congress and Trump will handle those latter payments, which are the subject of a federal court case and have been wrapped up in the repeal battle.

According to Vox’s Dylan Scott, Rand Paul plans to vote for “skinny repeal” but also says he doesn’t think an American Health Care Act– or Better Care Reconciliation Act-type bill would pass the Senate if it emerges out of a House-Senate conference. Paul himself could have a lot to say about that, given that he, Murkowski and Collins would be enough to sink a conference bill. Paul was one of nine Republican senators to vote against the BCRA last night. All of this is pretty screwy. Senate leadership is selling Republicans on “skinny repeal” not so much on its own terms, but as the only way to keep hope alive for another shot at an AHCA-type bill after the conference. But some members, like Paul, will vote for skinny repeal because they like it on the merits, seemingly hoping the conference will *not* yield an AHCA-type bill.