with Paulina Firozi


Even conservatives acknowledge that the sickest Americans need help in paying their own steep insurance costs. In an ironic twist, some would rather have the government make up the difference rather than spreading expenses among the healthy.

Health insurance markets are so complicated, and the policy around them is so complex and intertwined, that politicians don’t always land ideologically on the issue where you’d think. Just look at how GOP Sen. Ted Cruz of Texas is trying to change the Obamacare overhaul that Senate Republicans will try to pass in the next three weeks before August recess. The former presidential candidate last week touted his ideas and on the Sunday shows yesterday, my colleague Sean Sullivan reports.

Cruz’s so-called “Consumer Freedom Amendment” -- which conservatives have been rallying around as the revision they most want -- would essentially free the healthiest Americans from covering the costs of the sickest Americans. But the sick would be even more heavily reliant on federal assistance as a result.

Cruz is one of the biggest skeptics in Congress of federal spending. But even he has acknowledged this increased need for government help under his proposal.

“You would likely see some market segmentation” Cruz told Vox last month. “But the exchanges have very significant federal subsidies, whether under the tax credits or under the stabilization funds.”

The Cruz amendment, which is being scored by the Congressional Budget Office as one of several potential changes to the Senate health-care bill, would result in segmenting the individual insurance market into two groups, experts say. Under it, insurers could sell cheaper, stripped-down plans free of Obamacare coverage requirements like essential health benefits or even a guarantee of coverage. These sparser plans would appeal to the healthiest Americans, who would gladly exchange fewer benefits for lower monthly premiums.

But insurers would also have to sell one ACA-compliant plan. The sickest patients would flock to these more expansive and expensive plans because they need more care and medications covered on a day-to-day basis. As a result, premiums for people with expensive and serious medical conditions like diabetes or cancer would skyrocket because all those with such serious conditions would be pooled together.

“The question is, would there be a premium spiral on the ACA-complaint market?” said Cori Uccello, a senior health fellow with the American Academy of Actuaries. “Can they ever price those premiums adequately if it’s just going to be the sickest people in there?”

It's true that government subsidies -- which under the Senate plan would be available to those earning up to 350 percent of the federal poverty level -- would be even more crucial in order for these sicker Americans to afford the cost of their coverage, as would an extra infusion of federal “stabilization” money for states to cover their steep expenses.

Cruz hasn’t laid out all the details of how his amendment would work, nor is it even certain Senate Majority Leader Mitch McConnell (R-Ky.) will accept it as part of his health-care bill. But should it be adopted, and the Senate bill ultimately made law, the Cruz amendment would significantly shift how the individual insurance market operates.

But in Cruz’s mind, it would solve one of the biggest problems with Obamacare: that it robs the healthy to pay for the sick. He's spent the last week pitching it as the legislative solution for passing the Senate bill.

“I think really the consumer freedom option is the key to bringing Republicans together and getting this repeal passed,” Cruz said on ABC yesterday

Of course, everyone paying into the system for those who most need care is the way insurance is fundamentally supposed to work. The ACA requires insurers to offer a wider ranger of benefits in plans sold to everyone regardless of their health status. But to Cruz and his compatriots, requiring healthier people to buy cushier plans than they want or need is an abridgment of personal freedom and oversteps federal regulatory authority. So they’re more worried at the moment about rolling back more ACA regulations and less worried about federal spending.

“I think for conservatives it’s become a question of picking their poison,” Larry Levitt, president of the Kaiser Family Foundation, told me. “Is it government spending, or regulation? It’s almost like with this amendment, Sen. Cruz is acknowledging the need for a government entitlement program.”

Conservative groups that want a much fuller Obamacare repeal than the Senate bill provides have been jumping on the Cruz bandwagon, including Club for Growth, FreedomWorks and Tea Party Patriots.

From Tea Party Patriots founder Jenny Beth Martin:

On the flip side, the Cruz amendment could help kill the Senate health-care bill in the end because it's prompting fears among moderates (whose votes are also needed to pass the legislation) that patients with preexisting conditions could be harmed. 

“I think that reopens an issue that I can’t support, that it would make it too difficult for people with preexisting conditions to get coverage,” Sen. Shelley Moore Capito (R-W.Va.) told the Charleston Gazette-Mail.

Cruz has said the Senate bill's $100 billion stabilization fund for states could help cover costs for the resulting pricier coverage for those with preexisting conditions under his amendment. And to parry concerns about the increased federal spending, which to some is more than ironic coming from Cruz? The  talking point Capitol Hill aides and conservative wonks are adopting: Directly subsidizing costs for those with preexisting conditions is a more “honest” approach by the government than forcing healthy people to indirectly pay for their care by buying comprehensive coverage.

“If you’re going to have a subsidy, have it come directly from the taxpayer and call it a subsidy rather than try to dragoon people to do the government’s work,” said Chris Jacobs, a former GOP Hill staffer and founder of Juniper Research Group.

“It’s more honest and fair to have the government than to have healthy, middle-class families pay for it,” Conn Carroll, a spokesman for Sen. Mike Lee (R-Utah) said.

A co-sponsor of Cruz's amendment, Lee is insisting it be added to the Senate bill before he’ll vote for it. Sens. Rand Paul of Kentucky and Ron Johnson of Wisconsin have sent similar signals. And remember -- if more than two Republicans defect, the measure would be sunk in the Senate and the GOP effort to repeal-and-replace Obamacare would most likely meet a bitter end.

Some exciting news over at The Daily 202 from my colleague James Hohmann, whose newsletter makes its debut on Amazon Echo devices and Google Home as a flash briefing called "The Daily 202’s Big Idea." Every morning, you can listen to James analyze one of the day's most important political stories, along with three headlines you need to know. To learn how to add The Daily 202’s Big Idea to your flash briefings on your Echo device or Google Home, visit this page. You can also get the briefing on Apple Podcasts or wherever you get your podcasts.


AHH: Brenda Fitzgerald, Georgia's public health commissioner, will lead the Centers for Disease Control and Prevention, under an appointment announced late last week by the Trump administration. Fitzgerald, 70, an obstetrician-gynecologist who has headed Georgia's public health department since 2011, will succeed Tom Frieden, who stepped down in January. She's currently president-elect of the Association of State and Territorial Health Officials -- the nonprofit group that represents the nation's public health agencies -- and she has strong ties to Republican leaders in and from Georgia, including Health and Human Services Secretary Tom Price, my colleague Lena Sun writes.

"Within CDC, Fitzgerald's actions will be watched closely to discern whether she will allow politics to overrule science — as other Trump administration officials have been accused of doing — and whether she will be able to advocate effectively in Washington," Lena writes. "On hot-button issues such as abortion, she condemned graphic antiabortion ads aired by her GOP opponent in her first bid for elected office, saying the government had no business dictating abortion policy."

Public health organizations praised her appointment, as did Price, who said in a statement that Fitzgerald has a "deep understanding of medicine, public health, policy and leadership." Frieden also welcomed the appointment. “It's a good thing that she has experience running a public health agency,” he said. “That’s critically important to being successful at CDC.”

OOF: Former Rep. Donna F. Edwards writes in a Post op-ed that she was diagnosed last year with multiple sclerosis, in a piece urging Congress to maintain protections for people with preexisting conditions. The Maryland Democrat recounts the day she learned about her diagnosis last year, while still a member of the House.

“I finally got my diagnosis after nearly two months of tests and analysis. It came June 22, 2016 — the day of the House sit-in in support of gun-control legislation," Edwards writes. "That morning, I went to the House floor to join the sit-in. But hours into our protest, the House attending physician called me to his office to tell me I had multiple sclerosis, an autoimmune disease that attacks the central nervous system. At first, I couldn’t process what he was saying. I thought I had a pinched nerve; I didn’t know anything about MS. Devastated, I blinked away my tears and went back to the chamber, where I stayed for the remainder of the evening.”

Edwards says her medication for MS costs about $73,000 a year, writing that she’s not sure what she'll do when her COBRA coverage expires in June. She and other patients with serious health conditions would be harmed through the House and Senate bills overhauling Obamacare, she writes.

"If we return to a time when people with preexisting conditions can be charged more than healthy people, it will surely result in my never being able to afford insurance again," Edwards writes. "If we return to a time of lifetime caps, I will no longer have health insurance.”

OUCH: An online campaign has raised about $1.7 million to send Charlie Gard, the British infant who was born last August with infantile-onset encephalomyopathic mitochondrial DNA depletion syndrome, to send him to the United States to get additional treatment. Charlie's parents are fighting to get their son the experimental treatment that has so far been blocked by British courts.

The family awaits another hearing today, The Post's Kristine Phillips and Lindsey Bever report. The hospital asked England's High Court to to rehear the case after researchers at two other hospitals shared new evidence about the treatment Charlie could potentially receive. The High Court of Justice had ruled in April that withdrawing life support was in the boy's best interest to avoid prolonged suffering, and the European Court of Human Rights had rejected the parents' appeal last month. 

The saga has captured the attention of conservative groups and members of Congress. Republican Reps. Brad Wenstrup (R-Ohio) and Trent Franks (R-Ariz.) say they will introduce a bill in the House this week to grant the family permanent residence in the United States. “Our bill will support Charlie’s parents’ right to choose what is best for their son, by making Charlie a lawful permanent resident in the U.S. in order for him to receive treatments that could save his life,” the congressmen said Friday in a joint statement.


--President Trump tweeted this morning that he can't imagine Congress would leave for the long August recess without passing an Obamacare overhaul for him to sign -- but we at The Health 202 can easily imagine such a scenario. 

Trump also tweeted this warning yesterday:

--Toward that end, the White House and Senate Republican leaders are planning a final, urgent blitz to pressure reluctant GOP senators to pass an overhaul of the Affordable Care Act before their month-long break, my colleagues Kelsey Snell, Sean Sullivan and Robert Costa report.

"Aware that the next 14 days probably represent their last chance to salvage their flagging endeavor, President Trump, Vice President Pence and Senate Majority Leader Mitch McConnell (R-Ky.) intend to single out individual senators and escalate a broad defense of the evolving proposal, according to Republicans familiar with their plans," my colleagues write.

As Trump returns from Europe, he plans to counter official estimates that the Senate health-care bill would cause millions fewer to have health coverage with figures and analysis from conservative groups and Republicans that show more benefits and less disruption. Pence is being asked to help bring along skeptical GOP senators, including Sen. Dean Heller (Nev.), to whom he has already reached out personally.

And McConnell is expected to place greater responsibility on Cruz to pitch his "Freedom" amendment. "McConnell could ask Cruz to speak to Republican senators as soon as Tuesday...Cruz has often talked about his amendment in the senators’ regular Tuesday lunches, but the burden of building support for the bill could be left to the firebrand conservative," my colleagues write.


--Amid all the flash-and-dash, Republicans as they return to Capitol Hill are increasingly uncertain that a major legislative victory is achievable in the next three weeks. "Most immediately, GOP leaders and President Trump are under enormous pressure to approve health-care legislation — but that is only the beginning. Virtually every piece of their ambitious legislative agenda is stalled, according to multiple Republicans inside and outside of Congress," The Post's Mike DeBonis and Ed O'Keefe report.

"They have made no serious progress on a budget despite looming fall deadlines to extend spending authorization and raise the debt ceiling. Promises to launch an ambitious infrastructure-building program have faded away. And the single issue with the most potential to unite Republicans — tax reform — has yet to progress beyond speeches and broad-strokes outlines....The fallout, according to these Republicans, could be devastating in next year’s midterm elections. A demoralized GOP electorate could fail to turn out in support of lawmakers they perceive as having failed to fulfill their promises, allowing Democrats to sweep back into the House majority propelled by their own energized base."

Sen. Chuck Grassley (R-Iowa), easily one of the top three senators with the best Twitter feed, warned of this very possibility:

Sen. John McCain (R-Ariz.) predicted the Republican bill to roll back Obamacare would likely fail in the Senate if put to a vote. (Reuters)

--Two GOP senators are already predicting the health-care bill is "dead." “My view is it’s probably going to be dead,” Sen. John McCain (R-Ariz.) said on “Face the Nation” yesterday. But he also quipped: “But I’ve been wrong… I thought I'd be president of the United States.”

And Sen. Bill Cassidy (R-La.) said he doesn't even know what the plan is at all. “Clearly, the draft plan is dead. Is the serious rewrite plan dead? I don’t know," Cassidy said on Fox News Sunday.

--Dozens of protesters organized by a coalition of left-wing groups were arrested nationwide last week after occupying the local offices of Republican senators to protest the health-care bill, my colleague Dave Weigel reports. The #SitInSaveLives protests took place in Arizona, Arkansas, Florida, Kentucky, Louisiana, Missouri, Ohio and Wisconsin, organized by chapters of Democratic Socialists of America, Socialist Alternative, Indivisible, Our Revolution and the Working Families Party. A sampling of their social media promotion:

In some cities, like Denver’s protest aimed at Sen. Cory Gardner (R-Colo.) and Phoenix’s protest targeting Sen. Jeff Flake (R-Ariz.), activists refused to leave and were detained by police. From Denver's Democratic Socialists chapter:

In other cities, law enforcement stopped disruptions before they could start. In Philadelphia, Ultraviolet activist Melissa Byrne tweeted that the Department of Homeland Security was used to keep protesters out of the office of Sen. Patrick J Toomey (R-Pa.). But in Ohio, activists found themselves able to stay overnight in the offices of Sen. Rob Portman (R-Ohio):

--Some other good reads from around the web:



  • The Senate returns from its July Fourth recess today. The House returns on Tuesday.

Coming Up

  • The Bipartisan Policy Center is holding an event on solutions to long-term care financing Tuesday.
  • The Hazelden Betty Ford Foundation will hold a “national town hall” on Wednesday on the opioid crisis.
  • The House Energy and Commerce Subcommittee on Health will hold a hearing on examining medical product manufacturer communications on Wednesday.
  • The Hill is hosting an event on "The Cost of Caring: Family Caregivers and Tax Reform," featuring Sen. Tammy Baldwin (D-Wis.), Sen. Joni Ernst (R-Iowa), Rep. Dan Donovan (R-N.Y.) and Rep. Michelle Lujan Grisham (D-N.M.) on Thursday.
  • The Bipartisan Policy Center will hold an event on Thursday on state flexibility in health care.

McConnell says repealing Obamacare now and delaying a replacement 'doesn't work':

Senate Majority Leader Mitch McConnell says “the private health insurance market is imploding” and that delaying the health care replacement “doesn't work.” (Reuters)

Republican senators can't escape health-care protests, even outside D.C:

The debate over the Senate’s embattled health-care bill followed Republican senators home over the fourth of July recess. (Meg Kelly, Jenny Starrs/The Washington Post)

Sen. Lisa Murkowski (R-Alaska) says she’s reached out to Democrats on health care: 

Sen. Lisa Murkowski (R-Alaska) said that she's reached out to Democrats in hopes of a bipartisan health-care deal. (Kyle Hopkins for The Washington Post)