What Went Down On Health Care This Week

The Senate is voting now on an amendment proposed by Sen. Steve Daines, Republican of Montana, to create a single-payer health care system. Daines, like the other Republicans, does not really support a single-payer system, and said he will not vote in favor of his amendment. (Daines said he copied the text of his amendment from this House bill.) His goal, rather, is to put Democrats’ votes on the record on an issue that’s divisive within the Democratic Party. But Sen. Bernie Sanders of Vermont, an independent who caucuses with the Democrats and has his own bill for implementing single-payer health care, has said he won’t participate in the Daines amendment and urged others in the Democratic caucus to vote “present.” Voting “present” relieves red-state Democrats from having to either go on the record supporting single payer or risk angering the more liberal wing of the party.

It’s been hard to make reliable predictions about exactly how the health care debate will play out. The general rule has been that Republicans are never as close to passing a bill as they seem to be at their best moments, nor never as far from it as they seem to be at their worst ones. But whereas “skinny repeal” seemed to have a lot of momentum initially — with Heller indicating he would back it, for example — the news so far today has been more troubling for its prospects. Here’s a sampling:

• House Freedom Caucus chair Mark Meadows said there’s “not enough appetite” to pass “skinny repeal” in the House as currently constructed.
• South Dakota Sen. Mike Rounds said he wanted a guarantee that “skinny repeal” wouldn’t pass the House, or that its implementation would be delayed.
• Arizona Sen. John McCain said he’s still undecided on “skinny repeal.”
• And various provisions that were supposed to be in the “skinny repeal” bill keep getting nixed by the Senate parliamentarian, meaning they’d require 60 votes (or for the GOP to eliminate the legislative filibuster) to pass.

So … who knows. Fundamentally, however, McConnell is playing a game of three-card Monte with his caucus. Some members (like Heller) are willing to vote for “skinny repeal” only in order to avoid having to vote for something like AHCA or BCRA, while others (like Rounds) want to vote for “skinny repeal” only because they hope it turns into something like AHCA or BCRA after conference with the House. It might be a neat trick if McConnell pulls it off, but it was never going to be easy.

One thing worth bearing in mind throughout the next crazy hours of Senate debate: Senate Majority Leader Mitch McConnell chose to approach the GOP effort to repeal and replace parts of the ACA using the reconciliation process. The benefit of this process for the GOP is that it needs only 50 votes to pass — with Vice President Mike Pence as tiebreaker — so the party doesn’t have to work with Democrats to craft or pass the bill. The down side is that there are limitations on what can be included in the bill, because each provisions must be primarily about making changes to the budget. It also puts a deadline on passing the bill for complicated reasons. The Senate parliamentarian, who determines whether the bill follows those rules, has issued guidance that many of the GOP ideas included in the various iterations of Senate legislation proposed so far don’t comply. That includes provisions that would:

• Restrict funding for Planned Parenthood.
• Allow insurers to charge older adults five times as much as younger adults.
• Institute a six-month waiting period to buy insurance if you haven’t had continuous coverage (which is supposed to function as a replacement for the individual mandate).
• Make available waivers to allow states to forgo insurance market regulations.

Getting rid of these provisions makes Swiss cheese out of the bills Republicans have put forward so far. It’s unclear what that will mean for their final bill proposal. At the moment, two of the options seem to be to leave those provisions out (as would be the case with a true “skinny repeal” bill that just ended the individual mandate, the employer mandate and perhaps a few other things) and hope they can get enough votes without them, or they could choose to overrule the parliamentarian, ending the Senate as we know it.