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The Health 202: The Senate gets its ticket to ride on the health care roller coaster


The Senate can begin health-care discussions in earnest today when it finally gets an official word from the Congressional Budget Office on how much money there is to work with on an overhaul of President Obama’s health-care law.

Remember that crazy roller-coaster ride a few weeks ago, as the House started and stopped…and stopped and started…and finally gained enough speed to pass its health-care measure (and, I might add, gave reporters the legislative equivalent of motion sickness)? Ever since then, senators have been waiting in line for their own wild ride to start.

But now the cars can start chugging down the tracks, when the CBO releases its anxiously anticipated and final estimate of how much the House’s American Health Care Act would cost and how many people it would cover.

The House needs a final CBO score on its bill for political reasons. Republicans had very publicly called on Democrats to get a final estimate before passing Obamacare back in 2010. 

Remember this?

So when Republicans passed the AHCA with only preliminary scoring, Democrats hounded them:

But the Senate needs a CBO score for very practical reasons. Anything it wants to do regarding replacing the ACA hangs on this score. That’s because if Senate Republicans want to pass a health-care bill without any help from Democrats, they must use the budget bill currently housing the House health-care measure. Using the budget measure allows them to pass it with just a simple majority instead of the typical 60-vote threshold.

We know, we know. The term “CBO score” tends to make readers’ eyes glaze over. So instead, think of this cost-and-coverage estimate as an all-day pass to the amusement park of Obamacare repeal. It’s a crucial marker for the Senate as it tries to move toward replacing parts of the health-care law sometime this year.

“We’ll have to study it make sure the House bill fits the reconciliation process in the Senate,” a Senate GOP aide said. “Until we have a sense of how this all fits together and whether we’ll have to change policies to achieve deficit reduction, it’s hard to say what the timeline will be.”

Here are some top things we’re keeping our eyes on over at The Health 202, as the CBO releases its score (expected this afternoon):

1. Does the House bill save at least $2 billion?

The answer to this will be yes, in all likelihood. Per reconciliation instructions, $2 billion is the minimum sum it must save, and the most recent version scored by CBO saved $150 billion.

Savings in the final bill will be less -- after more high-risk pool funding was added along with a change that could lead to more federal spending on subsidies -- but will almost certainly still pass muster.

2. How much wiggle room is there to maintain more of Obamacare’s coverage expansions?

The difference between the House bill’s total savings and the $2 billion it must save equals the money available to maintain more benefits for Americans. Many senators are anxious to avoid the criticisms leveled at the House bill – that it would cause 24 million Americans to lose coverage in a decade – and so they want to offer more generous subsidies or more slowly phase out Obamacare’s Medicaid expansion.

But to do so, they’d have to either pay for it by drawing from the House bill’s savings, or adding back in more revenue, possibly by keeping some of the ACA’s taxes.

3. If the House bill achieves the required savings, does that mean the Senate could pass it lock, stock and barrel?

Not at all. The CBO is just one next step in the whole legislative  -- and political -- process. The health-care bill’s next big hurdle comes when the Senate parliamentarian rules whether its provisions qualify for what can be included in a budget bill. All of its elements must directly affect federal spending, according to the most common understanding of how the process works.

Experts agree there are many things in the House bill that the parliamentarian could very well strip out, including the parts that repeal many of the ACA’s insurer regulations.

Have fun on today's ride.


AHH: Voters have certainly raised a ruckus over the Republican health-care bill to overhaul Obamacare, but you know who hasn't? The insurer and provider CEOs whose companies could be dramatically affected by the changes the GOP is proposing. Few executives are wielding their influence publicly to shape the legislation that could have a dramatic impact on their companies' bottom lines. Instead, they're hiding behind industry lobbying groups like America's Health Insurance Plans and the American Hospital Association.

"Just a handful of CEOs have raised concerns about the GOP bill," Shelby Livingston writes at Modern Healthcare. They include Paul Markovich (Blue Shield of California), Mark Bertolini (Aetna), Michael Dowling (Northwell Health) and Mario Molina (recently ousted from Molina Healthcare).

"But these candid executives are rarities," Livingston writes. "Elsewhere in the industry, it's crickets. Other health insurance CEOs from companies with a big stake in Medicaid or the individual market, such as UnitedHealth, Anthem and Centene, have kept quiet despite warnings from health policy experts who say the [American Health Care Act] could leave more than 20 million Americans without health insurance."

OOF: Others haven't been so quiet about their feelings on Trump and health-care. Famed surgeon and writer Atul Gawande fired off some angry tweets yesterday about the cuts to medical research, Medicaid and public health funding proposed in Trump's budget:

In that last tweet, Gawande was referring to the Agency for Healthcare Research and Quality, which received $324 million in direct funding this year. The Trump budget proposes folding the center into the National Institutes of Health and renaming it the National Institute for Research on Safety and Quality. The new center would be funded with $272 million from the NIH budget, with an additional $107 million from an existing trust fund for patient-centered outcomes research, according to Science

OUCH: With his budget proposal, Trump officially broke his promise that he wouldn't propose cuts to Medicaid. A lot of people have been circulating this tweet from when the president was campaigning two years ago:

But we should note that Trump did basically keep his promise about Medicare and Social Security. His budget barely touches those programs. But that meant the president had to look elsewhere (like Medicaid) to achieve the massive savings his budget claims, since Medicare and Social Security are the government's priciest entitlement programs. Trump also relies on some unusual budget tactics, my colleague Max Ehrenfreund explains:

"White House officials are boasting that President Trump's budget would balance federal finances in 10 years," Max writes. "Yet despite extreme reductions in spending on health care for the poor, food stamps, education, science and other basic government programs, Trump's staff could only balance the budget by claiming vague savings and unspecified sources of new revenue — in other words, with trillions of dollars in mystery money."

"It is not just that Trump is counting on a rapid acceleration in economic growth that economists believe is unlikely, which the budget projects will yield $2.1 trillion in new revenue ($2,062,000,000,000, to be more exact). Besides that bonus from growth, the budget also assumes that Trump's tax cuts — which he has said will be the largest in history —  would not affect the government's bottom line at all."


--Several Republicans joined Democrats, medical experts and children's advocates to push back Tuesday against some of the cuts in the White House budget. Senate Finance Committee Chairman Orrin G. Hatch of Utah and House Appropriations Committee Chairman Harold Rogers of Kentucky said the overall budget would reduce coverage for children in families who make too much to qualify for Medicaid but not enough to afford comprehensive health plans, my colleague Juliet Eilperin writes.

Less surprisingly, many Democrats pushed back too. Here are some of their more clever tweets:

--The health wars have already claimed one casualty in Rep. Tom MacArthur (R-N.J.), a moderate former leader of the Tuesday Group who helped broker the House health-care compromise with conservative Freedom Caucuser-ers. My colleague Bob Costa interviewed MacArthur yesterday about why he stepped down from his perch:  MacArthur "said he decided to leave the post over the weekend after concluding that he no longer had the group’s support ... the centrists MacArthur once led are increasingly nervous about their reelection chances — and have groused that his eagerness to cut a deal with Freedom Caucus hard-liners is partly responsible for their vulnerability."

Here are some key quotes from Bob's interview with MacArthur, who said some Republicans would prefer privately to keep Obamacare in place:

  • "I think part of my realization over the past few weeks is what has rankled my Tuesday Group colleagues the most is that I negotiated with the House Freedom Caucus."
  • "I do think the people who have struggled the most [with my involvement in the negotiations] are those who voted no on the House bill."
  • "I think there are people who wanted the Republican bill to stay dead, who didn’t want it revived. They didn’t want to vote."

--Senators met again yesterday to discuss writing their own health-care bill, but few new details emerged. One senator, however, did some grousing to reporters about how the whole thing is taking place behind closed doors instead of out in the open in committee hearings.

“It’s a very awkward process, at best,” Sen. Bob Corker (R-Tenn.) told reporters. “There are no experts. There’s no actuarials. … Typically, in a hearing, you’d have people coming in and you’d also have the media opining about if a hearing took place, and X came in and made comments.”

Corker added that the way things are being done could create some "blind spots." "To me, I’d rather have the input as we move along than a bill be produced and all of a sudden it’s the product and then everybody opines," he said. Asked if he’s raised these concerns with party leaders, he replied, “Oh, of course.”


--The new FDA commissioner, Scott Gottlieb, sent out an agencywide email on Tuesday outlining some possible policy changes that could help curb the opioid crisis. My colleague Laurie McGinley got her hands on the letter, in which Gottlieb called the epidemic his "highest initial priority" and called on the FDA to consider "more forceful steps" to reduce the number of new cases of addiction.

"Gottlieb suggested that the agency consider mandatory education for doctors about the dangers of opioids and work to ensure that patients aren't prescribed the medications for unnecessarily long periods that increase the risk of addiction...the FDA has been criticized by some in the public health community and on Capitol Hill for not moving more forcefully to counter the opioid crisis," McGinley writes.

Gottlieb also announced he's creating an Opioid Policy Steering Committee made up of senior FDA officials to develop new strategies for confronting the epidemic, and charged the panel with exploring three areas:

--Whether FDA should require health-care professionals to get education about public health recommendations around opioids.

--Whether FDA should take additional steps to ensure opioid prescriptions more closely fit patients' medical needs.

--Whether FDA is using the proper framework to assess the risk of misuse as it's approving a new drug.

--Yesterday, the governing body of the World Health Organization elected the first-ever WHO director-general from Africa. Tedros Adhanom Ghebreyesus, a former Ethiopian health minister, will lead the agency at a time when it's responding to infectious disease epidemics such as Ebola and Zika.

"The election comes at a critical time for the WHO," the Post's Lena Sun writes. "It has experienced huge budget cuts over the years, lost many talented staff members and was heavily criticized for its slow and ineffective response to the 2014 Ebola epidemic in three West African countries that killed more than 11,000 people. A recent editorial in the Lancet said the election comes at a time of 'unparalleled uncertainty' for the organization."

Here are some other good reads from the health-care world:

Trump budget contains little on drug prices despite tough talk (Bloomberg)

'Where do you live?' (Politico)

Major Blue Cross Blue Shield insurer reverses ACA losses (Axios)

Six states hoping to revamp Medicaid in the Trump era (Governing)

Trump's budget proposal aims to cut all federal funds from Planned Parenthood (Lindsey Bever)



  •  The Congressional Budget Office will release their score today on the American Health Care Act, which passed the House earlier this month. The CBO estimated in March that a previous version of the AHCA would cover 24 million fewer people by 2026 than if Obamacare remained fully intact. 
  • Both the Senate and House Budget committees will meet to discuss the Trump administration’s budget, which is proposing drastic cuts to the social safety net.

Coming up:

  • Montanans head to the polls tomorrow to fill Interior Secretary Ryan Zinke’s former seat in Congress. Election observers still give the edge to Republican Greg Gianforte, but Democrats are hoping that they can land a victory in part because of voters’ low opinion of the AHCA.
  • The investigatory arm of the Senate’s Homeland Security and Governmental Affairs Committee will convene Thursday to consider “stopping the shipment of synthetic opioids.”



Watch Stephen Colbert stage a Twitter-vention for Trump:

Here's Bono discussing on Jimmy Kimmel how he feels about Trump: