What Went Down On Health Care This Week

The Senate is reportedly moving toward voting on a “skinny repeal” which would end the ACA’s individual mandate, its employer mandate, and its medical device tax. Yesterday, Harry pointed out one of the political virtues of this repeal strategy: It targets the individual mandate, one of the least popular elements of the ACA. While some in the GOP leadership clearly see the proposal as just a way to get to a conference committee, anything that is passed by the Senate has a real chance of becoming law. That said, the Republicans shouldn’t leap to the conclusion that a “skinny repeal” would be as popular as the individual mandate is unpopular. Back when the ACA was being adopted and implemented, some Democrats argued that the Affordable Care Act would become more popular over time because its component parts polled better than the legislation itself. The table below, for instance, comes from a 2011 Kaiser Family Foundation poll that asked about support for 15 separate pieces of the ACA. As you can see, the law’s individual elements poll very well — even the Medicare tax on high earners gets 59 percent favorable ratings.

The ACA polls better in pieces

Share of survey respondents with favorable views of ACA provisions, 2011

PROVISION	FAVORABILITY
Easy-to-understand health plans	84%
Small business tax credit	80
Financial help to low/moderate income Americans	75
Medicare donutnut hole	74
Independent reviewer	74
Expand Medicaid	69
Pre-existing conditions	67
Government review premium increases	66
Eliminate co-pays and deductibles	64
Employer mandate	63
Insurance company rebates	60
Increase Medicare payroll tax	59
Increase premiums of high income Medicare people	57
Mandatory minimum package benefits	53
ACA overall	37
Individual mandate	35

But notice that the law’s overall favorability — 37 percent — is just a shade above that of the lowest-rated element, the individual mandate, which polls at 35 percent favorable. (Remember, this Kaiser poll is from 2011; the ACA has become more popular since then.) In other words, citizens’ overall evaluations of the ACA are in no way an average of their feelings on the law’s individual elements. And if the “skinny repeal” leads to rising premiums and insurers’ withdrawal from the marketplaces, it’s unlikely to be as popular as the public’s opposition to the individual mandate would imply. In assessing bills, the whole picture is rarely a sum of the parts. Tiger Brown, Saleel Huprikar and Louis Lin provided research assistance.

At this point, you should be listening very carefully to what Nevada’s Dean Heller says, perhaps more than any other senator. Susan Collins and Lisa Murkowski have voted against the motion to proceed, “repeal and delay” and “repeal and replace.” So they seem like they are going to be “no” on whatever the final Republican bill is, or at least the hardest to sway. Of the 52 Republican senators, 49 voted for either “repeal and delay” or “repeal and replace.” Heller is an outlier: He voted for the motion to proceed, which kept the bill alive, but then voted against both versions of repeal. Heller defended Medicaid on the Senate floor in a speech Wednesday and offered an unsuccessful resolution praising the program. What Heller seems to want is a bill that repeals parts of Obamacare (so he can tell conservatives back home that he followed through on that, and so he can get President Trump off his back) but one that does not include the cuts to traditional Medicaid and the Obamacare Medicaid expansion that have been in most of the drafts of “repeal and replace.” That sounds like the “skinny repeal,” and Heller suggested Wednesday that he could vote for that. But Heller has also indicated that he cares about the views of Nevada Gov. Brian Sandoval, also a Republican. And on Wednesday night, Sandoval signed onto a letter that suggests a repeal of the individual mandate, one of the ideas involved in the narrow repeal, will cause a spike in premiums. So stay tuned to the Dean Watch; it really matters.

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.