Obamacare is often referred to as a three-legged stool: Americans must buy health insurance, insurers must sell them generous benefits without discriminating and the government provides subsidies to help pay for it all. Using that metaphor, let's consider how Senate Republicans have struggled to pass an Obamacare repeal bill over the past two days.
First, Republicans tried to chop off all three legs with a bill replacing much of the Affordable Care Act. That failed Tuesday night.
Then, they tried to chop off just the first and third legs -- the individual mandate to have coverage and the subsidies -- in a repeal-only bill that failed yesterday.
Now, they're down to a third potential option: Chop off just one leg -- the individual mandate -- and leave the stool lopsided.
No. 3 Senate Republican John Thune said yesterday that they're "edging closer and closer" to 50 votes for this "skinny repeal" option, my colleagues Juliet Eilperin, Kelsey Snell and Sean Sullivan report. Details are still emerging, and could always change quickly, but the aim is to pass a bill repealing just the ACA's individual and employer mandates, its medical device tax and its public-health fund. Funding for extra Obamacare subsidies for cost-sharing discounts may be attached, too, and the legislation may also retain a provision blocking Medicaid reimbursements from Planned Parenthood clinics.
Once passed, the bill could be sent to a conference committee where members of the House and Senate could hash out an agreement. Leaders are betting Republican senators who defected on other votes this week would feel enough pressure at that point to support whatever the final measure looks like. Kaiser Family Foundation senior vice president Larry Levitt noted that it could look very different from "skinny repeal:"
Of course, if “skinny repeal” is just an effort to get to a conference committee, who knows what ultimately comes out of that process.— Larry Levitt (@larry_levitt) July 26, 2017
It would be awfully hard for Republicans and President Trump to avoid completely owning the insurance market if "skinny repeal" became law.— Larry Levitt (@larry_levitt) July 26, 2017
But if Senate Republicans voted for this skinny repeal today or tomorrow, they'd be backing policy that would undermine the already shaky individual insurance market, result in fewer covered Americans and drive up premiums.
Here's what is likely to happen under the "skinny repeal" approach: Without the individual mandate to buy coverage, some people -- disproportionately healthy ones -- would opt out of health coverage, worsening the risk pools and driving up premiums. According to new Congressional Budget Office estimates released last night by Senate Democrats, 16 million fewer Americans would have health insurance next year compared to current law, and individual market premiums would increase 20 percent on average (although the proposal would save the government money because fewer people would be enrolling and accessing subsidies).
"You're talking about cutting one leg off a three-legged stool," Linda Blumberg, a senior health-policy fellow at the Urban Institute, told me. "Keeping the subsidies in place, the stool may be able to rest on the stump and not completely fall over, but you are going to see the effects of that by significantly higher premiums."
Granted, Obamacare's individual mandate hasn't worked as well as everyone originally thought. Many analysts concluded the penalty for failing to buy coverage is just too small, set at either $695 or 2.5 percent of one's income, whichever is higher. That's much less than most people would pay in monthly premiums over the course of a year. Plus, the government has few tools for collecting the penalty -- it can't garnish peoples' wages or have them arrested, for example. It can only draw the penalty from a taxpayer's tax refund, if they have one.
But here's the irony: Republicans say it's essential that they repeal Obamacare because it's destroying the individual insurance market -- but this "skinny repeal" approach wouldn't fix the marketplaces and would probably make them quite a bit worse. Insurers would still be subject to the ACA's sweeping coverage requirements that they offer specific benefits and cover even the sickest, most expensive patients (called "guaranteed issue" and "community rating"), but without the promise the healthy must sign up too.
The irony gets even deeper when you consider that the bare-bones bill would cause premiums to rise, even though Republicans have made lowering premiums a central demand in their quest to repeal the ACA. That's actually why three Senate conservatives -- Sens. Ted Cruz of Texas, Mike Lee of Utah and Marco Rubio of Florida -- said they opposed a repeal bill the House passed in 2015.
Like the potential "skinny repeal" for which Senate Majority Leader Mitch McConnell (R-Ky.) is currently gauging support, the 2015 House bill would have ditched only a few parts of the ACA -- including its individual and employer mandates, medical device tax, prevention fund and a few other provisions. At the time, Cruz, Lee and Rubio said the House bill didn't go nearly far enough.
“This simply isn’t good enough," the trio said in a joint statement. "Each of us campaigned on a promise to fully repeal Obamacare and a reconciliation bill is the best way to send such legislation to President Obama’s desk. If this bill cannot be amended so that it fully repeals Obamacare pursuant to Senate rules, we cannot support this bill. With millions of Americans now getting health premium increase notices in the mail, we owe our constituents nothing less.”
Indeed, most Republicans do understand the need for an incentive for people to buy coverage to create a functional insurance market. Both versions of the House and Senate bills to replace the ACA contained penalties for those who didn't maintain continuous coverage -- violators would have to pay higher premiums under the House bill and they'd have to wait six months to enroll under the Senate version. And a bill proposed in 2015 by Sens. Richard Burr (R-N.C.), Orrin G. Hatch (R-Utah) and Rep. Fred Upton (R-Mich.) also required people to maintain continuous coverage if they wanted protection against being denied coverage or being charged higher premiums based on their health status.
A group of Senate Republicans -- including 27 members still holding office -- submitted a brief to the Supreme Court back in 2012 when the ACA was being challenged as unconstitutional. In it, they argued that the individual mandate is the "heart" of the health-care law, and without it, both the number of uninsured Americans and premiums would skyrocket (Yale's Abbe Gluck explains more here).
And many conservative health policy experts agree repealing only the individual mandate is a crummy idea.
"Having guaranteed issue and community rating without some sort of mandate is structurally a rather dangerous thing to do," Robert Graboyes, a health-care scholar at the Mercatus Center. "It's an invitation to a death spiral."
As for insurers, they're terrified that Republicans are considering "skinny repeal" as a possibility. The Blue Cross Blue Shield Association came out yesterday against "skinny repeal," saying it's "critical" for a health-care bill to include strong incentives for people to obtain health insurance and keep it year-round.
"A system that allows people to purchase coverage only when they need it drives up costs for everyone," BCBS said in a statement.
Democrats, who are mostly standing on the sidelines as Republicans undergo 20 hours of health-care debate this week, are firing hard at the "skinny repeal" idea:
House Budget Dems:
GOP's "skinny" repeal idea => bloated premiums for you and your family. https://t.co/ujswGXCYhp— House Budget Dems (@HouseBudgetDems) July 26, 2017
From Sen. Elizabeth Warren (D-Mass.):
"Skinny repeal" should be called "gut it and run." Voting to destroy insurance markets and kick millions off health care remains immoral. pic.twitter.com/D8N1Jlk6tD— Elizabeth Warren (@SenWarren) July 26, 2017
If the Senate passes "skinny repeal" – which guts the marketplace – premiums will skyrocket. Insurers will quit.— Elizabeth Warren (@SenWarren) July 26, 2017
From Sen. Dick Durbin (D-Ill.)
.@SenateGOP, let’s be clear: voting yes on a “skinny repeal" is giving the Freedom Caucus full rein to destroy our health care system.— Senator Dick Durbin (@SenatorDurbin) July 27, 2017
House Minority Whip Steny H. Hoyer (D-Md.):
The Senate has rejected repeal & replace & straight repeal. It's time to work together to improve ACA. https://t.co/dtuZX376sI— Steny Hoyer (@WhipHoyer) July 27, 2017
|You are reading The Health 202, our must-read newsletter on health policy.|
|Not a regular subscriber?|
AHH: The Senate is on its third day of health-care debate. Late Tuesday, senators voted down an Obamacare repeal-replace bill. Yesterday, they defeated, in a 45 to 55 vote, a repeal-and-delay bill offered as an amendment by Sen. Paul. Today, members are gearing up for a loooong vote-a-rama starting possibly this afternoon, in which dozens of amendments can be offered. Want to understand how this all works? My colleague Kelsey Snell has a super-duper helpful explainer here. And here's a tracker from The Post's Kim Soffen:
OOF: Eric Cantor, the former House majority leader who was ousted in 2014, admits he never believed Republicans would follow through on their many promises to repeal Obamacare, in a candid interview with the Washingtonian. Cantor played a huge role in driving Obamacare repeal as a core GOP message in the years just after the health-care law was enacted. Asked whether he feels partly responsible for his party's current predicament, Cantor responded "Oh, 100 percent."
“To give the impression that if Republicans were in control of the House and Senate, that we could do that when Obama was still in office . . . .” Cantor said, shaking his head. “I never believed it.”
Cantor also said he wasn’t the only one aware of the charade. “We sort of all got what was going on, that there was this disconnect in terms of communication, because no one wanted to take the time out in the general public to even think about ‘Wait a minute—that can’t happen,'" Cantor said. But he added this: “If you’ve got that anger working for you, you’re gonna let it be.”
"It’s a stunning admission from a former member of the party leadership—that the linchpin of GOP electoral strategy for the better part of a decade was a fantasy, a flame continually fanned solely because, when it came to midterm elections, it worked," Elaina Plott writes.
OUCH: Tom Price, head of the Department of Health and Human Services, is being candid too. Yesterday, Price told CNBC that Senate Republicans need to aim for the "lowest common denominator" to keep the quest for an ACA repeal bill alive.
"What gets us to 50 votes so that we can move forward on a health-care reform legislation ... that's what needs to happen. And that status quo isn't working out for folks out there in the real world," Price said. "Legislation is one step at a time. And so we'll see what the next step is and move on from there."
President Trump is glued to the health-care scene unfolding in the Senate chamber. His tweet this morning:
Come on Republican Senators, you can do it on Healthcare. After 7 years, this is your chance to shine! Don't let the American people down!— Donald J. Trump (@realDonaldTrump) July 27, 2017
--The administration is reportedly making threats to Sen. Lisa Murkowski, one of two moderate Republicans who voted against even starting health-care debate. According to a report from the Alaska Dispatch News, Murkowski's office -- and the office of Dan Sullivan, Alaska's other senator -- received phone calls yesterday afternoon from Interior Secretary Ryan Zinke letting them know the vote had put Alaska's future with the administration in jeopardy.
Sullivan called the call from Zinke a "troubling message." "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 told the Dispatch News.
"I tried to push back on behalf of all Alaskans," he added. "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."
Trump had blasted Murkowski in a tweet earlier on Wednesday:
Senator @lisamurkowski of the Great State of Alaska really let the Republicans, and our country, down yesterday. Too bad!— Donald J. Trump (@realDonaldTrump) July 26, 2017
--Rep. Buddy Carter (R-Ga.) aimed some crude language at Murkowski yesterday, saying on MSNBC that someone needs to go to the Senate and “snatch a knot in their a**.”
“I think it’s perfectly fair," Carter said, defending Trump's criticisms of the Alaska Republican.
"Let me tell you, somebody needs to go over there to that Senate and snatch a knot in their a**," Carter said in response to a question from Ali Velshi. "I’m telling you, it has gotten to the point where how can you say I voted for this last year, but I’m not going to vote for it this year.”
The clip, from MSNBC's Kyle Griffin:
A helpful definition of "snatch a knot," for those of us who never heard the term before:
--Senate Republican leaders have little room to navigate as they try to craft a skinny bill, as just three defections within their ranks would deprive them of the 50 votes they need to pass legislation (assuming a tiebreaking vote by Vice President Pence). In each of the two most important votes the Senate has cast since taking up the bill, at least 13 percent of Republicans defected to join Democrats in opposition.
“This certainly won’t be easy. Hardly anything in this process has been,” McConnell said on the Senate floor yesterday.
"In an effort to muster enough votes for a narrow bill, GOP leaders suggested that even some proposals that have died in the Senate could come up again once they enter negotiations with the House," my stellar colleagues write. "Senate Majority Whip John Cornyn said proposals offered by Sens. Rob Portman (R-Ohio) and Ted Cruz (R-Tex.) that were rejected Tuesday as part of a broader rewrite measure could resurface."
Sen. Graham said that a scaled-back bill “is not a solution to the problem” but there did not appear to be another option. He appears willing to go along with "skinny repeal" — but only if he is assured that another plan he has offered along with Sen. Bill Cassidy of Louisiana would be reconsidered.
Cassidy has been earnestly touting that plan:
On with @CNN shortly to discuss health care. The Graham-Cassidy amendment is the best way forward to take care of patients.— Bill Cassidy (@BillCassidy) July 26, 2017
--Seven (seven!) Republicans voted yesterday against a repeal-only bill -- even though nearly all of them voted for the same bill back in 2015, when it was assured President Obama would veto it. The defectors included: Sens. Susan Collins of Maine (she was the "no" vote previously), Lamar Alexander of Tennessee, Shelley Moore Capito of West Virginia, Dean Heller of Nevada, John McCain of Arizona, Lisa Murkowski of Alaska and Rob Portman of Ohio.
Alexander's reasoning, per HuffPost's Jennifer Bendery:
"Pilots like to know where they’re going to land when they take off & we should too." -Sen. Alexander, who opposed O-care repeal-w/o-replace— Jennifer Bendery (@jbendery) July 26, 2017
--Senate Democrats will reject an amendment offered by GOP Sen. Steve Daines (R-Mont.) designed to smoke out support for a single-payer system, my colleague Dave Weigel reports. A spokesman for Sen. Bernie Sanders (I-Vt.) called it a "sham."
The Daines amendment, which the Montana senator has admitted he won’t actually vote for, will propose the text of a House “Medicare for All” bill. Democrats view it as a ploy to get some of the party’s more vulnerable senators to vote “against single payer,” angering the party’s base.
--Meanwhile, this emerging "skinny repeal" strategy faces serious headwinds in the House, with lawmakers already skeptical differences between the two chambers can ever be bridged, my colleague Mike DeBonis reports.
"House Republicans who fought tooth and nail over the course of months earlier this year to expand the scope of the repeal legislation are saying 'fat chance' to the skinny repeal — including key members on the conservative and moderate ends of the GOP — and say it is difficult to see what legislative product could span the divide between the chambers," Mike writes.
“I don’t think it’s going to be very well received,” said Rep. Mark Walker (R-N.C.), chairman of the conservative Republican Study Committee. The group with dozens of members met Wednesday and had a “fairly negative” reaction to the skinny-repeal plan, Walker said.
Rep. Mark Meadows (R-N.C.), chairman of the House Freedom Caucus and a key player in the negotiations that produced the House bill, told reporters in recent days that a skinny bill would be “dead on arrival” in the House and that a conference committee would have to be convened to work out a compromise:
Per Bloomberg's Sahil Kapur:
.@RepMarkMeadows just said there’s “zero” chance the House would pass a skinny repeal of ACA. Then he made a hand-signal that read zero.— Sahil Kapur (@sahilkapur) July 26, 2017
A few more reads from the Post and beyond:
- A health-care rally is planned for Saturday in Washington, D.C.
Republicans and Democrats make their cases during Senate health-care debate:
Senate Minority Leader Charles E. Schumer (D-N.Y.) on health-care debate: ‘What kind of process is this?’
Sen. Lindsey O. Graham (R-S.C.) said he and Sen. Bill Cassidy (R-La.) are introducing a health-care amendment that would maintain taxes on the wealthy established under Obamacare: