What Went Down On Health Care This Week

There were three late-breaking health care developments on Wednesday night. In order of importance: 1. A CBO score Senate Democrats had asked the Congressional Budget Office to analyze a health care bill that included six provisions: repealing the individual mandate, repealing the medical device tax, repealing the employer mandate, defunding Planned Parenthood and repealing two different public health funds. The first three ideas, in particular, are considered likely to be part of whatever repeal bill Senate Republicans propose next. On Wednesday night, the budget office put out three tables, not a full analysis. CBO estimated that the plan would result in an additional 16 million Americans being uninsured, compared to under current law, including more than 7 million who would not be covered under Medicaid. The budget office did not precisely explain the decline in insurance coverage, but it would likely be, in part, the result of people choosing not to get insurance because of the lack of the mandate, which under Obamacare requires them to purchase coverage or be fined. People choosing not to get insurance might not sound like the worst problem, but health experts say that if more healthy people do not have to get insurance, they won’t, and that this would wreck the Obamacare marketplaces and drive up costs for those who do use them. CBO, at least in what it released publicly, did not detail how the lack of a mandate would affect premiums in the healthcare marketplace. But such an analysis is likely to show a major spike in premiums. David O. Barbe, head of the American Medical Association, which has been critical of the GOP health policy push, said, “Eliminating the mandate to obtain coverage only exacerbates the affordability problem that critics say they want to address. Instead, it leads to adverse selection that would increase premiums and destabilize the individual market.” And even without that premium analysis, 16 million is a big number. This is not great news for Republicans. 2. The Sandoval factor Senate Democrats released a letter signed by 10 governors — five Republicans (John Kasich of Ohio, Brian Sandoval of Nevada, Charlie Baker of Massachusetts, Larry Hogan of Maryland and Phil Scott of Vermont) and five Democrats (John Hickenlooper of Colorado, Steve Bullock of Montana, Terry McAuliffe of Virginia, Tom Wolf of Pennsylvania and John Bel Edwards of Louisiana,) — that said, “The Senate should also reject efforts to amend the bill into a ‘skinny repeal,’ which is expected to accelerate health plans leaving the individual market, increase premiums, and result in fewer Americans having access to coverage.” The important signatory is Sandoval. Nevada Sen. Dean Heller, a key swing vote in the Senate debate, has emphasized that he will take counsel from Sandoval. It is not clear if Heller will decide his vote based on Sandoval’s position, but the governor’s rejection of “skinny” repeal could be significant. 3. The Democrats The Senate is officially still in its 20 hours of debate in this process. But Senate Minority Leader Chuck Schumer said on Wednesday night that Democrats will essentially stop participating until Senate Republicans show them whatever the bill is that the GOP ultimately wants senators to vote on. Schumer called the current process a “sham” and called on McConnell to release the real bill so that the two parties can debate it. Schumer is right: Once the “repeal and delay” and “repeal and replace” bills were defeated, the rest of the votes that happened on Wednesday (and will occur on Thursday) are almost certain to go down. Senators are essentially offering amendments to a bill that does not exist. (Tomorrow afternoon, Republican Steve Daines of Montana is expected to ask the Senate to vote on an amendment that would create a single-payer-like health care system. This is essentially Senate trolling, trying to get some more moderate Democratic senators to vote against an idea championed by liberal members like Bernie Sanders and show a split in the Democratic Party. Daines does not support this idea himself.) But McConnell has very little incentive to release his legislation early. For one, he may not actually have written anything yet that 50 Republican senators support. Second, if the bill is skinny repeal similar to what the CBO analyzed, public scrutiny will do no favors for McConnell. McConnell may be violating norms and limiting public accountability. But he’s already very far down that road now, having held a secretive process and bypassed Senate committees. It’s hard to expect he will start behaving in a more traditional way now.

The Senate will hold more votes on health care, many of them largely symbolic, on Wednesday night and into Thursday morning. But we have reached the point in the Senate’s health care debate when the most important action will be happening off of the Senate floor for awhile. The Senate’s main two Obamacare bills — “repeal and replace” and “repeal and delay” — have both been rejected. Republicans are working, behind closed doors, on some kind of limited repeal plan that they hope can pass (the so-called “skinny” repeal). Senators have suggested that that plan would roll back the individual mandate, the employer mandate and the medical device tax. But the contours of the “skinny” repeal are likely to change, depending on what senators will support and what follows the rules of the reconciliation process. I expect a Friday vote on whatever Senate Republican leaders come up with and determine has the support of at least 50 senators. So watch this space tonight and tomorrow for our take on wacky votes, but more importantly on the ideas that Senate leaders float for a bill that can get 50 votes, how rank and file GOP senators react to them (particularly Nevada’s Dean Heller, who seems like he is now the key swing vote) and if policy experts think these proposals are viable and will improve or hurt the U.S. healthcare system. (A “skinny” repeal seems like a political solution that has lots of policy problems.) Also, now that senators are openly talking about taking whatever they pass into a conference with the House, the reactions of House Republicans are worth watching as well — and we’ll be tracking them too.

Weeks ago, the conventional wisdom had been that the GOP did not want to drag out its work on health care reform. When the Senate took up health care reform in late June, for instance, there was talk that Paul Ryan would keep the House in session to pass whatever bill emerged from the Senate’s deliberations before July 4. The goal was to rip off the Band-Aid, so to speak, and move on to other items on the GOP agenda. Now, the talk is instead that the Senate just needs to pass a bill, any bill, to get to conference, meaning that the goalposts have moved substantially. But why would the Senate and House’s joint negotiators be able to thread a needle that has eluded Mitch McConnell for the past few months? It’s certainly possible that proximity to final passage will give the GOP momentum — and that once key members have cast a vote to repeal Obamacare, they’ll want to see the policy through to enactment. But it’s not a sure thing. Negotiations on the repeal efforts have been described as a Rubik’s Cube or a whack-a-mole game, where any one solution generates a new problem elsewhere. That dynamic is unlikely to get any easier during a negotiation across chambers. The GOP — both its leadership and key swing votes — has a strong incentive to bring these repeal efforts to a close. The fact that they are now talking about punting to a conference committee indicates both how committed they are to repeal and how hard coalescing around any specific proposal has become.