What Went Down On Health Care This Week

Alaska Sen. Dan Sullivan told the Alaska Dispatch News that Interior Secretary Ryan Zinke, a Trump appointee, called both Sullivan and Alaska Sen. Lisa Murkowski on Wednesday afternoon in the wake of Murkowski’s votes against the Republican effort to repeal Obamacare. Sullivan, according to the Dispatch News, described the call with Zinke as having a “troubling message.” He implied Zinke had threatened to withdraw some federal money from Alaska if Murkowski did not get on board with the Obamacare repeal effort. “I’m not going to go into the details, but I fear that the strong economic growth, pro-energy, pro-mining, pro-jobs and personnel from Alaska who are part of those policies are going to stop,” Sullivan said, according to the paper. “I tried to push back on behalf of all Alaskans. … We’re facing some difficult times and there’s a lot of enthusiasm for the policies that Secretary Zinke and the president have been talking about with regard to our economy. But the message was pretty clear,” Sullivan said. Sullivan was fairly vague about what Zinke said, but Erica Martinson of the Alaska Dispatch News wrote, “Sullivan said the Interior secretary was clear that his message was in response to the no vote Murkowski cast Tuesday on the motion to proceed with debate on the House-passed health care legislation.” Sullivan told the paper that Zinke had also called Murkowski. The White House, the Interior Department and Murkowski’s office did not reply to Martinson’s requests for comment. (I recommend you read her whole story here.) I suspect that if the story weren’t true, the Trump administration would have denied it. Here’s the thing: It’s not that unusual for party leaders in Congress or the White House to squeeze members of their own parties, demand that they vote for things and suggest they will face repercussions (lack of fundraising support for their next campaign, not putting a military base or other job-creating federal facility in that member’s state or district) if they refuse. This happens in both parties, usually behind the scenes. President Trump himself made this kind of squeeze more publicly last week, when he all but said that the GOP would not support Nevada Sen. Dean Heller’s re-election effort in 2018 unless he got behind this health policy legislation. But here’s why I think this specific effort was clumsy. First, calling Sullivan was odd. Sullivan can’t control Murkowski’s vote, but he can tell the press that the Trump administration is threatening Alaska. Maybe the Trump administration thought Sullivan would stay quiet in public but implore Murkowski to vote for the bill behind the scenes. That did not happen. (On the other hand, maybe Trump’s team just wants the threat out there.) Secondly, there’s no hint that Murkowski regrets her vote. “I’m very comfortable with the decision I made,” she told reporters Wednesday, according to The New York Times. Moreover, she has voted against both health care proposals brought to the Senate floor (“repeal and replace” and “repeal and delay.”) I might be wrong about this, but it seems to me that Murkowski’s vote is lost already, so she may not be the best target for aggressive tactics from Trump’s team. Third, Trump may be creating a Murkowski problem. She is not up for re-election until 2022, unlike Heller. It looks like Trump is getting mad at her, as his Wednesday tweet blasting the senator suggested. Trump might be smart to avoid tactics that embolden Murkowski to oppose him not just on health care, but on other issues as well.

As Perry mentioned yesterday, the Democrats asked the Congressional Budget Office to score a health bill that includes repeal of the individual and employer mandates, two key pieces of the “skinny repeal” that seems most likely to emerge from the Senate GOP’s deliberations. You might think that the significant majority of insurance losses under such a plan would come from employer-based coverage and individually purchased coverage (such as on the exchanges). But if I’m reading the report right, one of the striking findings is that by the end of the next decade, nearly half the insurance losses would come via Medicaid. That’s related to the “woodwork effect,” which is the fact that a significant share of the increases in the insured population under the ACA came from people who were already eligible for Medicaid before 2014. So while policymakers might think about the various provisions of the ACA as separate, they work in concert.

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.