with Paulina Firozi
But the Senate bill contains three elements McConnell is betting will win over a half dozen or so moderates who remain skeptical but whose votes are crucial to overall passage (remember: the majority leader needs only 50 votes since arcane budget rules are being applied to the measure, meaning he can lose just two Republicans). McConnell's draft, hashed out behind closed doors, basically retains Obamacare's insurance subsidy structure -- with just a few tweaks -- takes a gentler approach than the House bill in the short-term to Medicaid expansion, and wouldn't allow states to opt out of key protections for patients with preexisting conditions.
The idea, aides and lobbyists say, is to provide a softer landing for people at lower ends of the income spectrum than under the House bill. That measure based the subsidies only on age and didn't peg them to actual premiums, resulting in estimates of dramatic cost spikes for some Americans and prompting a heavy onslaught of public criticism that spooked many House moderates.
The Senate bill tries to fix that problem -- sort of. Its subsidies closely mirror Obamacare subsidies, which are currently available to Americans earning between 100 percent and 400 percent of the federal poverty level. Starting in 2020, under the Senate bill, this assistance would be capped for those earning up to 350 percent — but anyone below that line could get the subsidies if they’re not eligible for Medicaid. As under the ACA, the subsidies would be pegged to a benchmark insurance plan each year, ensuring that the assistance grows enough over time to keep coverage affordable for customers.
McConnell is also offering moderates an approach to Medicaid he hopes will be more politically palatable to them. It's true the draft proposes even deeper cuts to Medicaid than the House version by tying federal spending to a slower growth index. But that wouldn't kick in for another seven years, well past moderate senators' next reelection battles. And it doesn't fully end the ACA's Medicaid expansion until five years from now, gradually easing down the extra federal payments over three years starting in 2021.
The Senate bill also retains the ACA's protections for patients with preexisting conditions. It eliminates the House bill's pathway for states to lift a ban on insurers from charging people with serious medical conditions higher premiums, which would have been another political hotbed for moderates. It does expand the use of certain "1332 waivers" to give states more flexibility -- a provision that conservatives like Sen. Ted Cruz (R-Tex.) wanted -- but those waivers don't open the door to ducking the preexisting protections.
The Senate bill would also provide funding in 2018 and 2019 for extra Obamacare subsidies to insurers to cover the cost-sharing discounts they’re required to give the lowest-income patients. Insurers have been deeply concerned over whether the subsidies will continue, as the Trump administration has refused to say whether it will keep funding them in the long run.
With this approach that sticks a little closer to existing law, McConnell is hoping to win over Republicans in states that embraced parts of the ACA, like Lisa Murkowski of Alaska, Rob Portman of Ohio, Shelley Moore Capito of West Virginia and Dean Heller of Nevada. Their votes are absolutely crucial to the whole effort to repeal and replace parts of Obamacare, the promise Republicans made time and time again over the past seven years and which McConnell is determined to fulfill. He will present the draft to his wary members at a 9:30 meeting this morning in a pivotal gathering.
Even yesterday, many members expressed deep skepticism toward elements in the draft as it took shape. “Up to this point, I don’t have any new news — tomorrow we will see it definitively — that would cause me to change that sentiment,” Capito told my colleagues Sean Sullivan, Kelsey Snell and Juliet Eilperin yesterday.
Many moderates are still likely to be displeased that the Senate draft will almost certainly result in significantly more uninsured people than under the ACA, although it could look a little better than the House version on that measure, which is estimated to cost 23 million people their coverage in a decade. All of this won't be known for sure until the Congressional Budget Office score is released, likely on Monday. Furthermore, the measure retains a provision to strip Medicaid funds from Planned Parenthood clinics for one year, potentially alienating Murkowski, who supports abortion rights.
So what do conservatives get out of this bill? Big cuts to Medicaid further down the road and a repeal of nearly all of Obamacare's taxes. Under the Senate draft, federal Medicaid spending would remain constant for three years. In 2021, it would be transformed from an open-ended entitlement to a system based on per-capita enrollment. Starting in 2025, the measure would tie federal spending on the program to an even slower growth index, which in turn could prompt states to reduce the size of their Medicaid programs.
Conservatives, and the health-care industry at large, will also be pleased that the draft proposes repealing all of Obamacare's taxes except for its so-called “Cadillac tax” on high-cost health plans in language similar to the House version. Senators previously toyed with the idea of keeping some of the ACA’s taxes.
But there's a strong chance the Senate bill could spark a revolt on the right. Conservative groups like the Heritage Foundation and Americans for Prosperity wanted to erase Obamacare's Medicaid expansion right away, and they're also likely to view the Senate GOP's approach to subsidies as another big, bad government entitlement. Antiabortion groups may oppose the measure too since it could remove the House bill language restricting federally subsidized health plans from covering abortions, which may have run afoul of complex budget rules.
Aides stress the GOP plan is likely to undergo more changes to garner the votes Republicans need. It's in discussion draft form, meaning elements could be added or stripped out over the next week as Republican leaders try to propel it toward a vote before the end of next week. And there are ongoing conversations with the Senate parliamentarian over which provisions can even be included under rules governing what can go in a budget reconciliation bill.
And don't forget that even if this bill passes the Senate, there's another steep hurdle. It would have to pass muster with the more conservative House before heading to President Trump's desk for a signature. And the House already had a difficult time passing its own version, meaning none of this is assured to become law.
To help you follow along, The Fix's Amber Phillips and the Post's graphic team will keep tabs on who supports and who opposes the Senate bill in the runup to the expected vote next week with a Whip Count. And the Post will write about developments as the draft gets released this morning here and here with our health-care liveblog.
|You are reading The Health 202, our must-read newsletter on health policy.|
|Not a regular subscriber?|
Some observers noted the similarities between the Senate bill and the ACA. From the senior VP of the Kaiser Family Foundation:
Reports of the Senate health bill look like Obamacare-lite for private insurance. The Medicaid changes are a horse of a different color.— Larry Levitt (@larry_levitt) June 21, 2017
If the Senate health bill cuts off premium subsidies at 350% of poverty, the effect will be greatest for older people in high premium areas.— Larry Levitt (@larry_levitt) June 21, 2017
The associate director of the Kaiser foundation noted the effect the measure would have on people who don't qualify for subsidies:
Sen. Ron Johnson just called their health care bill a "modification" of the House bill. So at least they're admitting that now.— Tierney Sneed (@Tierney_Megan) June 21, 2017
Trump in Iowa says he wants health care "with heart."— Jennifer Jacobs (@JenniferJJacobs) June 22, 2017
“I’ve been talking about a plan with heart. I’ve said, ‘Add some money to it.’"
From a veteran Democratic operative and Hillary Clinton deputy press spokesman:
A former Obama aide called those who drafted the Senate bill "monsters:"
You're not improving health care when you defund Planned Parenthood and deny millions of women their provider of health care.— Bernie Sanders (@BernieSanders) June 21, 2017
Democrats continued to attack the secret process:
As did Paul:
OOF: Insurance giant Anthem has announced it will leave the Obamacare marketplaces in Indiana and Wisconsin in 2018, my colleague Carolyn Johnson reports. The company said in a statement that the business of selling health coverage on the Affordable Care Act marketplaces has become "difficult due to a shrinking and deteriorating individual market, as well as continual changes and uncertainty in federal operations, rules and guidance, including cost sharing reduction subsidies and the restoration of taxes on fully insured coverage."
Anthem's announcement came yesterday, the deadline for insurers to tell federal regulators whether they plan to keep selling marketplace plans next and if so, how much they would like to charge. The deadline applied to all 39 states whose marketplaces are run by the federal government. An evolving map by the Kaiser Family Foundation shows that 44 counties in four states, where about 30,000 people buy insurance through the marketplaces, are at risk for having no insurance options next year.
The day was something of a moment of truth for the marketplaces, whose health depends on how many insurers participate, Carolyn writes.
"So far, states are seeing mixed results: One major insurer has made a big pullout, while a different one announced it would expand into new states," Carolyn reports. "Oscar Health, a start-up company that was co-founded by Ivanka Trump's brother-in-law, announced it would expand in Ohio, New Jersey, Texas, Tennessee, California and New York."
In Indiana, MDwise Marketplace announced it would leave that state's marketplace, putting four counties at possible risk of having no insurer next year, although a different Centene has announced it is expanding in the state. A spokeswoman for Centene said the company was still working through the filing process and would not share information until it was complete, Carolyn reports.
As the marketplace situation becomes more clear over the next few days, it will influence the urgency with which Republicans pass a bill replacing big parts of the ACA and puts more pressure on the Trump administration to respond to insurers asking for more certainty.
"To date, there has not been a county with zero insurers selling policies on its marketplaces, and it's not totally clear what will happen if a county is left without any plans. It's possible, however, that without a functional exchange, would-be participants would have to shoulder the full costs of their health insurance -- or go without," Carolyn writes.
AHH: President Trump is still calling for a final health-care plan “with heart.” As Senate Republicans prepared to released their discussion draft this morning, and details of the draft were starting to emerge, the president expressed his desires for the bill to an audience at a rally in Iowa last night.
“I can’t guarantee anything, but I hope we’re going to surprise you with a really good plan,” Trump said in Cedar Rapids, Iowa.
"We basically can’t lose anybody," he added.
His comments follow reports that he had privately called the House version of the bill “mean.” This was after Trump had celebrated the passage of the bill with members of the House in the Rose Garden.
Democrats, including Rep. Al Franken (D-Minn), jumped on the opportunity to use the presidents words against him.
What do you call a bill that would reinstate annual and lifetime caps? MEAN.— U.S. Senator Al Franken (@SenFranken) June 21, 2017
What do you call a bill that defunds Planned Parenthood, which provides critical health services for millions of women? MEAN.— U.S. Senator Al Franken (@SenFranken) June 21, 2017
What do you call a bill that will cause 23 million more people to be uninsured? MEAN.— U.S. Senator Al Franken (@SenFranken) June 21, 2017
What about a bill that guts Medicaid (which covers 1 in 5 adult women & pays for 1/2 of all births) to give tax breaks to richest few? MEAN.— U.S. Senator Al Franken (@SenFranken) June 21, 2017
OUCH: According to a Politico/Morning Consult poll, the Republican health-care bill has become less popular than when the House advanced its version last month. Just 35 percent of voters support the House version of the bill, and 49 percent disapprove of it. That’s down from 38 percent approval and 44 percent disapproval immediately after the bill passed in May.
- The Senate Appropriations Subcommittee on Health and Human Services, Education and Related Agencies holds a hearing on the budget request for the National Institutes of Health on Thursday.
- The American Enterprise Institute is holding a discussion on the government’s role in medical innovation and funding on June 29.
House Speaker Paul D. Ryan on health care: "This law is collapsing"
See Trump blame Democrats for the health-care deadlock: