No Insurance, but for 3 Days, Health Care Is Within Reach
by Nicholas Kristof - NYT - July 27, 2017
WISE, Va. — For a man who needed 18 teeth pulled, Daniel Smith was looking chipper.
Anxious, too, for he was facing a pair of forceps. But Smith, 30, a contractor with no health or dental insurance, who hadn’t seen a dentist in more than 20 years, was looking forward to an imminent end to the pain and rot in his mouth.
“I’ve always worked, since I was 14, but I’ve never had dental insurance,” Smith told me. After his teeth are out, he has a lead on low-cost dentures.
“I’d like to have a straight smile,” he said. “I’ve never had one in my life.”
All around Smith were uninsured patients receiving free dental or medical care, including dozens of men and women in side-by-side dental chairs in the open air. Organizers mercifully arranged the long line of people waiting to have teeth pulled so that they were facing away from those currently enduring extractions.
The patients swamped the county fairground here for a three-day health extravaganza of free care organized by Remote Area Medical, an aid group that holds these events across the country. This one involved about 1,400 volunteers serving 2,300 men and women who needed care of every kind.
Some patients camped out for three days at the fairground gate before the clinic opened to make sure they would be treated.
The health fair reminded me of scenes I’ve witnessed in refugee camps in South Sudan. But here in America?
The sight is a wrenching reminder of how many Americans slip through the cracks. No other advanced country permits this level of suffering — and if the G.O.P. health care plan goes through, millions more will lose their health coverage.
“Walking around, listening to people, it breaks your heart,” said Gov. Terry McAuliffe, a Democrat, whom I encountered on the fairground. “We need a healthy work force, and this is a disgrace.”
“Shame on us as a nation,” McAuliffe added. “This is an embarrassment to our country.”
That’s what I feel, too: humiliation that Americans need to be rescued by a group originally intended to help people in the world’s poorest countries (mixed with pride at the altruistic spirit that attracted so many volunteers, paying their own expenses to come here). To me, the fundamental lesson is that even under Obamacare, too many people don’t have coverage, and we urgently need a single-payer universal health care system along the lines of Medicare for all.
Remote Area Medical is the brainchild of Stan Brock, 81, a onetime British cowboy who in the 1950s managed one of the world’s biggest ranches, overseeing 50,000 cattle in Guyana in South America.
When he was badly injured by a wild horse, Brock was told it would be a 26-day hike to the nearest doctor. So he recovered on his own — but began to think about supplying health care to deprived areas.
Brock ended up founding Remote Area Medical to work in places like the Amazon, Haiti and Uganda. But then one day he had a call from Sneedville, Tenn., where the hospital had just closed and the dentist moved out. “Can you come here?” the caller asked.
Brock loaded a dental chair on the back of a pickup truck and brought in a dentist as well — and 150 people lined up, desperate for oral care. The result is that while it continues some international work, Remote Area Medical also treats people in the world’s superpower.
Brock is a character: He discovered a species of bat that is named for him, and today he has no home but unrolls a pad each evening and sleeps on the floor of Remote Area Medical’s permanent offices in Tennessee. At 5 a.m. on the first day here, Brock opened the gate and began admitting people eager for care.
As they surged past, many stopped to thank him; one man had tears in his eyes as he did so.
“I wish Mr. Trump would come,” Brock told me. “The health of these people is appalling.”
Obamacare and the expansion of Medicaid have helped, but this health fair underscores glaring gaps in American coverage, especially for dental and vision care, in ways that affect us all.
In the vision tent, a patient couldn’t see even the biggest letter at the top of the eye chart. As he waited for glasses, a volunteer asked, “And how did you get here?”
“Oh, I drove.”
Jennifer Jolliffee, a volunteer, told of a 6-year-old boy who had behavioral problems, couldn’t read and struggled at school. Then he had his first vision screening, and his parents learned that he could barely see. Soon he was looking around in wonderment through glasses.
In another area of the fairground, doctors saw patients in private “rooms” created by sheets dangled from strings with clothespins. In one such room, Dr. Ross Isaacs saw William Powers, a former bulldozer operator with severe kidney problems, and outlined how Powers could maximize his chances of a kidney transplant. “I’ve got hope again,” Powers told me as he left.
As for Dr. Isaacs, he put it this way: “The success of this event is an indictment of our health care system.”
Senate Soundly Rejects Repeal-Only Health Plan
by Thomas Kaplan - NYT - July 26, 2017
WASHINGTON — The Senate on Wednesday soundly rejected a measure that would repeal major parts of the Affordable Care Act without providing a replacement, leaving Republicans still searching for a path forward to fulfill their promise of dismantling President Barack Obama’s signature health law.
Seven Republican senators joined Democrats to vote against the measure, which had been embraced by conservatives but could have left millions of people without health coverage.
The rejection of “clean repeal” laid bare the deep divisions within the Republican caucus about how best to proceed. The night before, nine Republicans, including both conservatives and moderates, voted against comprehensive legislation to repeal the health law and provide a replacement.
Without the votes to replace the health law or to simply repeal major parts of it, Senate Republicans appeared increasingly likely to try to pass a modest measure that would repeal only a few provisions of the law, such as the tax on medical devices and the requirements that most individuals have insurance and that large employers offer coverage to workers.
But even that narrow bill could have a significant impact on the nation’s health care system. Democrats on Wednesday night released a Congressional Budget Office analysis of the effects of repealing several provisions that could be part of a “skinny” repeal measure. The analysis found that the number of uninsured people would increase by 15 million next year compared with current law, and Democrats said they were told that premiums would be roughly 20 percent higher.
But the point of the narrow repeal measure would not be to enact it. Instead, Republicans are simply trying to get some measure to bring to negotiations with the House.
“I think people would look at it not necessarily based on its content, but as a forcing mechanism to cause the two sides of the building to try to solve it together,” said Senator Bob Corker, Republican of Tennessee.
Senator Chuck Schumer of New York, the Democratic leader, called that “a ruse to get to full repeal” and warned that hard-line Republicans in the House would apply pressure to reluctant moderate Republicans in the Senate.
A scaled-down bill would fall far short of what Senate leaders had aspired to pass. But if 50 senators could agree, with Vice President Mike Pence breaking any tie, such a bill would keep alive the effort to repeal the Affordable Care Act, under which about 20 million people have gained coverage.
“What we need to do in the Senate is figure out what the lowest common denominator is — what gets us to 50 votes so that we can move forward on a health care reform legislation,” Tom Price, the secretary of health and human services, said on CNBC.
That strategy would require conservative senators like Rand Paul of Kentucky, Ted Cruz of Texas and Mike Lee of Utah to vote for a measure that leaves the basic structure of the Affordable Care Act in place, hoping that House-Senate negotiations could produce a more ambitious repeal. Such senators have argued that far broader replacement legislation did too little to eradicate the health law.
And cracks are already showing.
“The skinny plan is not a replacement of Obamacare,” Senator Lindsey Graham, Republican of South Carolina, said. “Would it be better than Obamacare? Yeah. But that’s not the goal. The goal is to replace Obamacare.”
In a letter on Wednesday, 10 governors — five Republicans and five Democrats — urged the Senate to reject a “skinny” repeal measure. The Blue Cross Blue Shield Association, a major insurance trade group, warned senators about the consequences of repealing the mandate that most people have health coverage without otherwise incentivizing people to get and maintain coverage.
“A system that allows people to purchase coverage only when they need it drives up costs for everyone,” the association said.
With two legislative approaches having been rejected by Republicans — the comprehensive measure and then the repeal-only measure — Democrats were left wondering what exactly Republican leaders were cooking up, and how they could reasonably expect senators to vote on that legislation in just a day or two. Republican leaders have been plotting strategy and drafting legislation largely behind closed doors, with a final vote likely by Friday.
Republicans are seeking to pass a repeal bill under special budget rules that limit debate to 20 hours and preclude a Democratic filibuster.
Senate Republican leaders, including the majority leader, Mitch McConnell of Kentucky, have emphasized that senators would be free to offer any amendments they see fit. But Senator Ben Cardin, Democrat of Maryland, highlighted a major challenge that he and other senators face: How can they prepare amendments to legislation without knowing what they are amending?
“What is the bill that we are considering?” he asked. “It’s not the bill that Senator McConnell brought forward because that bill was defeated. It’s not the ‘repeal and we’re starting from a blank slate’ because that was defeated.”
Just a week ago, Mr. McConnell seemed to have failed in putting together a health bill that could pass the Senate. But he managed to persuade enough of his reluctant members to agree on Tuesday to vote for a procedural motion to take up the repeal bill that passed the House in May, and on Wednesday, he vowed to press forward with the repeal effort.
The vote on the repeal-only measure showed the changing political dynamics that Republicans have grappled with this year on health care. With Mr. Obama in the White House, they could pummel his health law, with their words and with their votes, but his veto pen still loomed.
The Senate passed a similar repeal-only bill in 2015, and only one current Republican senator, Susan Collins of Maine, voted against it at the time. But that measure was vetoed by Mr. Obama, while senators are now trying to pass a bill that will actually become law.
But the Congressional Budget Office said last week that the repeal-only legislation would increase the number of people who are uninsured by 17 million next year and by 32 million in 2026 compared with current law.
Senator Lamar Alexander of Tennessee, the chairman of the Senate health committee, was among the Republican senators who voted against the measure on Wednesday. He said he did not believe his constituents would like the idea of “canceling insurance” for millions of Americans and then “trusting Congress to find a replacement in two years.”
“Pilots like to know where they’re going to land when they take off,” Mr. Alexander said, “and we should too.”
‘Skinny’ Obamacare Repeal Would Clash With Republicans’ Health Care Promises
by Margot Sanger-Katz - NYT - July 25, 2017
If the current options for overhauling the health care system can’t get a majority of Senate votes, the majority leader, Mitch McConnell, has a new backup plan, according to senators and lobbyists: a simple bill that eliminates three of Obamacare’s least popular provisions.
The plan, which has been nicknamed “skinny repeal,” would eliminate the Affordable Care Act’s individual mandate, the employer mandate and a tax on medical devices, at least for a few years.
The upside of such a plan: Those provisions are unloved. The individual mandate forces Americans who go without health insurance to pay a tax penalty. The employer mandate subjects businesses to a lot of paperwork requirements. The medical device tax hits an industry that has lobbying pull with many Republicans and even many liberal Democrats. A plan that eliminated only these three parts might be plausibly sold as Obamacare repeal, and it would avoid many of the more controversial policy changes in other G.O.P. proposals.
One prominent Democrat once endorsed a plan very much like Obamacare without mandates: Barack Obama, when he was running for president in 2008.But, of course, there is a downside.
The individual mandate is unloved because no one likes being told what to do. But many independent analysts have concluded that, without a mandate, health insurance would become more expensive and cover fewer people. With the nudge of a mandate, more healthy people tend to buy insurance, reducing the average cost of coverage. Without one, the theory goes, mostly sick people buy insurance, and premiums rise to cover that sicker pool.
Fewer people would probably be covered under Medicaid, too. Over the last few years, signups for Medicaid have increased substantially, even among people who could have been covered before Obamacare expanded eligibility. Many of those people presumably didn’t realize they qualified for Medicaid and first tried to buy private insurance because of the mandate, before learning that they could get Medicaid and not have to pay a premium. Without a mandate, fewer people are likely to find their way into the program.
The Congressional Budget Office thinks that eliminating the individual mandate would have substantial negative effects on the insurance market, raising prices and reducing enrollment. It is hard to imagine that more insurers would wish to participate in this smaller, sicker market. The budget office still needs to evaluate a skinny repeal bill, but it seems likely that the reductions in coverage from a mandate repeal would save the federal government enough money for the bill to comply with budget instructions.
It is worth considering these effects in the context of Republicans’ criticisms of Obamacare itself. On the Senate floor Tuesday, Mr. McConnell assailed the health law as building unstable insurance markets and providing too little consumer choice. A skinny repeal would probably exacerbate those effects.
President Trump has often criticized Obamacare as making insurance premiums too costly, with deductibles that are too high. Repealing the individual mandate would increase premiums and do nothing about deductibles.
Republican leaders have assailed the health law’s large tax increases. This bill would repeal only one tax.
Congressional Republicans have complained about Obamacare’s burdensome insurance regulations, which limit consumer choice. All of those would stay on the books under skinny repeal.
Republicans have also said they want to make structural reforms to the Medicaid program, as other health bill drafts would do. The skinny repeal plan leaves Medicaid as is, including its expansion under Obamacare to cover more poor adults. (This may be a plus for several moderate senators who were concerned about Medicaid cuts in the other bills.)
There has been a mismatch all along between many of the Republicans’ critiques of current law and the likely outcomes of their reforms. But earlier bills grappled with the issues by trying to deregulate insurance markets or provide stabilization funds, even if analyses suggested that the changes would still increase consumer costs and the number of Americans without insurance. A skinny repeal bill, instead, leaves those policy goals to the side in an effort to find a slender majority of votes.
Why ‘Skinny’ Obamacare Repeal Is a Terrible Idea
by J.B. Silvers - NYT - July 27, 2017
Skinny is often read as good today. We like skinny jeans, skinny models and, apparently, skinny health reform. It is likely that the Senate, which has just rejected repeal-and-replace and repeal-without-replace bills, will vote on a “skinny repeal” of the Affordable Care Act. What does this actually mean, and what would it produce?
The proposal most often labeled “skinny” would repeal the insurance mandate for individuals and larger employers under the banner of choice and freedom — both standard objectives of conservatives. It also would repeal taxes on medical-device manufacturers and, perhaps, also on insurers, with the goal of reducing the costs that must be reflected in premiums.
On the surface, both of those changes seem modest and reasonable. But I can assure Congress, as a former insurance company chief executive, that they would lead to a bloated upscale version of the Medicaid expansion so hated by conservatives. The result would be not only the loss of coverage for millions of people but also an even bigger bill for the government to pick up.
You have to look at the dynamics of the insurance market to understand this. To survive, an insurer has to predict the risk of costly claims and to obtain sufficient enrollment to balance customers who need a lot of health care with enrollees who have few or no claims. This works because while an insurer can’t know the timing or severity of illness for an individual, it can estimate the average claims of a group of individuals fairly well.
In health care, some individual needs are predictable — young people use less, and those with chronic conditions demand more. The only way to obtain a reasonable average is to have a broad pool, like the employees of a company covered by a group plan.
The individual market never had this natural grouping, so premiums varied widely, as did coverage, if it was available at all. The Obamacare individual mandate was intended to produce a representative group and to keep average premiums in bounds.
But a variety of problems resulted in predictably higher premium rates for insurance exchanges. The mandated coverage for qualified health plans was broader, enrollment was skewed by pricing that favored older customers, and risk-reduction mechanisms were insufficiently funded. Most of those can be laid at the feet of the Republican Congress and of President Trump for his sabotage in limiting enforcement of the mandate, cutting enrollment efforts and threatening to withhold the risk-sharing payments for low-income enrollees.
As a result, insurance companies’ actuaries have filed rate increases in double-digit percentages based on expected higher claim costs — fewer healthy people have signed up — and on risks that they thought were shared by the government being shifted back to them. At the same time, underlying health care inflation is closer to about 4 percent. In addition, many insurers have simply left the market because of unpredictable government policy.
Others sticking it out have bet that their higher premiums, combined with the loss of competitors, will let them cover the higher risk. They are probably right. The widely predicted “death spiral” won’t happen: Subsidies provide a low ceiling on the net premium for over three-quarters of enrollees.
So what will it mean for individuals if the mandate is jettisoned in a “skinny repeal”? Those receiving subsidies will be largely immune to higher costs — their increased premiums will be offset by larger government subsidies — but it’s actually middle-income people without subsidies who will be priced out of the market.
Without the mandate, they will just return to their previous uninsured status, frequently turning into emergency-room patients and bad debts for hospitals and doctors. The Congressional Budget Office has estimated that, in a decade, about 15 million people would be hurt, including independent professionals and small-business employees.
Those remaining in the exchanges will be receiving much higher subsidies because of the higher premiums, making them very similar to existing Medicaid beneficiaries. This is why the likely outcome is a much bigger tab for the government.
In effect, a “skinny repeal” will result in an unintended expansion of ever larger government subsidies to the working poor. The difference is that those people will have higher incomes than allowed under normal Medicaid or the expanded Medicaid coverage that has been so controversial in red states.
Some liberals may consider this extension of Medicaid-like coverage to be good policy that provides an on-ramp for the working poor to higher incomes and jobs with benefits. Yet the loss of insurance for millions of others is a steep cost for that expansion.
Those Republicans who advocate “skinny repeal” as just a lighter version of “repeal and replace” are likely to be very surprised at the unintended result. Most important, this piecemeal approach is no way to do health policy.
Editor's Note:
The preceding clipping demonstrates very clearly why medical underwriting, the basis of commercial insurance, should not be allowed in financing health care. Medicare utilizes taxes, not insurance premiums, to finance basic care, thereby eliminating the need for medical underwriting and its associated complexity and expense. That's one of the reasons Medicare enjoys such broad popularity, and commercial health insurance does not!
- SPC
Senate Votes Down Broad Obamacare Repeal
by Thomas Kaplan and Robert Pear - NYT - July 25, 2017
WASHINGTON — The Senate voted narrowly on Tuesday to begin debate on a bill to repeal major provisions of the Affordable Care Act, but hours later, Republican leaders suffered a setback when their most comprehensive plan to replace President Barack Obama’s health law fell far short of the votes it needed.
The Tuesday night tally needed to reach 60 votes to overcome a parliamentary objection. Instead, it fell 43-57. The fact that the comprehensive replacement plan came up well short of even 50 votes was an ominous sign for Republican leaders still seeking a formula to pass final health care legislation this week.
For Republicans, the failure ended the day on a sour note, hours after a more triumphant scene on the Senate floor. Lawmakers from both parties had risen to their feet in the afternoon and applauded when Senator John McCain, Republican of Arizona, showed up in the chamber despite his diagnosis of brain cancer. He cast a crucial vote in favor of opening what promises to be a freewheeling, hard-fought debate over the future of the Affordable Care Act.
The 51-50 vote to start debate, with Vice President Mike Pence breaking a tie, came only a week after the Republican effort to dismantle a pillar of Mr. Obama’s legacy appeared all but doomed. It provided an initial win for President Trump, who pushed, cajoled and threatened senators in recent days to at least begin debating the repeal of the health care law.
But the victory could be fleeting: Senate Republicans still have no agreement on a repeal bill that they can ultimately pass to uproot the law that has provided health insurance to millions of Americans.
The Senate is now moving ahead with debate, amendments and ultimately a final vote in the coming days on legislation that would have a profound effect on the American health care system — roughly one-sixth of the United States’ economy. But it is entirely possible that by week’s end, the senators will have passed nothing.
“Now we move forward towards truly great health care for the American people,” Mr. Trump said from the White House Rose Garden, where he was holding a news conference with the visiting prime minister of Lebanon. “This was a big step.”
Only two Republicans, Susan Collins of Maine and Lisa Murkowski of Alaska, voted against the procedural motion, though at least several other Republicans had been seen as possible holdouts. No Democrats voted in favor of the motion.
The Tuesday night vote was on a comprehensive amendment that included disparate proposals calculated to appeal to conservatives and moderates in the Republican caucus.
One proposal, offered by Senator Ted Cruz, Republican of Texas, would have allowed insurers to sell stripped-down health plans, without maternity care or other benefits required by the Affordable Care Act, if they also sold plans that included such benefits.
“You shouldn’t have to buy what the federal government mandates you must buy,” Mr. Cruz said. “You should choose what meets the needs for you and your family.”
The amendment also included money to help pay out-of-pocket medical costs for low-income people, including those who buy private insurance after losing Medicaidcoverage as a result of the Senate bill. This proposal was devised by Senator Rob Portman, Republican of Ohio, and other senators from states that have expanded Medicaid under the Affordable Care Act.
But nine Republicans, spanning the party’s ideological spectrum, voted against the package.
The debate to come will have broad implications for health care and households in every state, and emotions are high.
Before senators voted to start the debate in midafternoon, protesters in the Senate gallery chanted, “Kill the bill, don’t kill us!” and “Shame, shame, shame!”
Despite his vote to move ahead, Mr. McCain offered harsh words for the secretive process by which Senate Republican leaders came up with their bill to repeal and replace the health law, and he delivered a pessimistic take on its chances.
“Asking us to swallow our doubts and force it past a unified opposition — I don’t think that’s going to work in the end, and probably shouldn’t,” Mr. McCain said, adding that it “seems likely” that the current repeal effort would end in failure. Still, Mr. McCain voted with Republican leaders in favor of the comprehensive replacement plan on Tuesday night.
Arizona is one of the 31 states that expanded Medicaid under the Affordable Care Act, and Mr. McCain’s remarks could reflect concerns of other senators from states that expanded Medicaid, including the junior Republican senator from his state, Jeff Flake.
“We are ground zero for the failure of the exchanges, but we are also an expansion state,” Mr. Flake said. “I think all of us are concerned that we don’t pull the rug out from people.”
Just before the Senate vote, the Democratic leader, Chuck Schumer of New York, made an impassioned plea to Republicans.
“We know that A.C.A. is not perfect,” Mr. Schumer said. “But we also know what you’ve proposed is much worse. We can work together to improve health care in this country. Turn back now before it’s too late and millions and millions and millions of Americans are hurt so badly in ways from which they will never, ever recover.”
Given the divisions within their caucus, Senate Republican leaders were considering a new approach to keeping their repeal quest alive: They could try to reach agreement on a slimmed-down bill that would repeal a few major provisions of the Affordable Care Act, like the penalties imposed on people who go without insurance and businesses that do not offer insurance to their employees. Republican leaders would not intend such a bill to become law, but they believe that it could win approval in the Senate.
That “skinny” bill could then be a basis for negotiations with the House.
Republican leaders in Congress have struggled all year to fulfill their promise of repealing the 2010 health care law. By a vote of 217 to 213, the House approved a repeal bill in early May, but only after Republicans overcame their own difficulties in that chamber.
Mr. Trump kept up pressure on the Senate on Tuesday with Twitter posts. After the procedural vote, he applauded the Senate, but was cutting toward Ms. Collins and Ms. Murkowski: “We had two Republicans that went against us, which is very sad, I think. It’s very, very sad for them.”
The successful procedural vote was also a moment of redemption, at least temporarily, for Senator Mitch McConnell of Kentucky, the majority leader, who just last week appeared to have failed in his effort to put together a health bill that could squeak through the narrowly divided Senate.
That said, it remained far from certain whether Republicans would be able to agree on a bill in the days to come — and what exactly the contents of that bill would be. Mr. McConnell promised an “open amendment process” in which members of both parties could propose changes.
“This is just the beginning,” Mr. McConnell said. “We’re not out here to spike the football.”
For weeks, Mr. McConnell has been promoting and revising a comprehensive bill that would repeal the health law while also replacing it, but he has struggled to nail down the support needed to pass that measure. The nonpartisan Congressional Budget Office has yet to assess the most complete version of that legislation, which includes the proposals by Mr. Cruz and Mr. Portman.
Without that assessment, the measure needed 60 Senate votes, and it failed that test on Tuesday night.
The Senate is also expected to vote on a measure that would repeal the health law without putting in place any replacement, but that approach does not appear to have enough support to pass, either.
That proposal resembles a bill passed by the Senate in 2015 and vetoed by Mr. Obama in early 2016. But it would increase the number of people who are uninsured by 32 million in 2026, the budget office said.
Mr. Portman had anguished for weeks over provisions of Mr. McConnell’s repeal bill that would make deep cuts in projected Medicaid spending and roll back the expansion of the program under the Affordable Care Act.
Mr. Portman voted to move ahead with the debate on Tuesday after being assured that the Senate would vote on his plan to provide financial assistance to people moving from an expanded state Medicaid program to private health insurance.
States could have used the money, totaling $100 billion, to help low-income people pay deductibles and other out-of-pocket costs when they receive medical care.
Mr. Portman worked on the plan with the Trump administration and with several other Republican senators from states that have expanded Medicaid, including Shelley Moore Capito of West Virginia and Dean Heller of Nevada.
Mr. Heller voted Tuesday to open the debate, but he made no commitment to vote for the repeal bill itself.
“If the final product isn’t improved for the state of Nevada, then I will not vote for it,” Mr. Heller said. “If it is improved, I will support it.”
Health Care Vote: Senate Rejects Repeal Without Replace
by Thomas Kaplan and Eileen Sullivan - NYT - July 26, 2017
• The Senate on Wednesday afternoon rejected a proposal to repeal major parts of the Affordable Care Act without providing a replacement. Follow the live vote trackerto see how each senator voted.
• President Trump lashed out Wednesday morning at Senator Lisa Murkowski of Alaska, one of two Republicans who voted on Tuesday against beginning debate on repealing the health law.
• Blue Cross Blue Shield warns senators against repealing the mandate that almost everyone have insurance without something to take its place.
Senate rejects ‘repeal only’ measure
The Senate on Wednesday rejected a measure that would have repealed major parts of the Affordable Care Act but would not have provided a replacement, signaling that the “clean repeal” bill that conservatives have embraced cannot get through Congress.
The vote, 45-55, underscored the bind that Republican leaders have found themselves in. Seven Republicans voted against the measure — Senators Shelley Moore Capito of West Virginia, Susan Collins of Maine, Dean Heller of Nevada, John McCain of Arizona, Rob Portman of Ohio, Lamar Alexander of Tennessee and Lisa Murkowski of Alaska — showing that repealing the health law without an immediate replacement lacks crucial support among Republicans.
But a more comprehensive measure that would have repealed major parts of the law with a ready replacement also came up short on Tuesday night.
With neither approach viable, Senate Republican leaders may have no choice but to fall back on a third choice: Push a far more limited measure that repeals parts of the Affordable Care Act, such as its mandate that most people have insurance and a tax on medical devices, but leaves most of President Barack Obama’s signature health law in place. Senators would then take their narrow bill into negotiations with the House, which passed a comprehensive measure to repeal and replace the Affordable Care Act.
Where did everything leave off Tuesday night?
Understandably, confusion is rife over what the heck is happening on the Senate floor: What was that vote Tuesday night? Why did Senator John McCain, Republican of Arizona, give that impassioned speech saying he would not vote for the Senate health care bill as it stands, then turn around and cast a yes vote on Tuesday night?
An explainer:
When the Senate voted 51-50 to begin debating the repeal of the Affordable Care Act, technically senators were bringing the repeal bill that was passed in the House to the Senate floor. For now, that is the bill that senators are trying to reshape.
On Tuesday night, Senate Republican leaders brought to the floor their most complete version of a plan to repeal and replace the Affordable Care Act. That measure had been worked out behind closed doors by the majority leader, Senator Mitch McConnell of Kentucky, and it would dismantle major parts of the current health care law, including the requirement that most people have health insurance.
But it also included an overture to Senate conservatives, a measure championed by Senator Ted Cruz, Republican of Texas, that would allow insurance companies to sell stripped down, low-cost insurance plans as long as they also offer insurance policies that comply with federal standards, including the requirement that plans cover “essential” services like maternity care, mental health treatment and prescription drugs.
For moderates, the legislation includes $100 billion to help pay out-of-pocket medical costs for low-income people.
Because that broad version of the Senate health care measure had not yet been assessed by the nonpartisan Congressional Budget Office, it needed 60 votes to overcome a Democratic objection that it violated Senate rules.
But it got only 43 votes, demonstrating that even after weeks of refining the legislation, Senate leaders still fell far short of enough support for their replacement plan, from both ends of the party’s ideological spectrum.
Mr. McCain had previously made clear that he wanted to secure amendments to that broad repeal-and-replace bill. The vote on Tuesday night could be interpreted as a sign of support for that general approach.
The debate goes on.
And what does McCain actually want?
On Wednesday, the Arizona Republican let his leaders know what he wants. Mr. McCain’s office said that he had filed three amendments meant to address concerns from leaders in his home state of Arizona, including the governor, Doug Ducey, a Republican.
Arizona is one of 31 states that expanded Medicaid under the Affordable Care Act, and the amendments would all address Medicaid. One of them would extend the phase out of the Medicaid expansion to 10 years, considerably longer than the bills under consideration. Another would increase the growth rate for Medicaid payments to states to better reflect health care inflation.
“Any reform to our health care system must reward states like Arizona that are responsibly managing their health care services and controlling costs – not penalize them,” Mr. McCain said in a statement, adding that the amendments would “ensure our citizens who are most in need do not have the rug pulled out from under them.”
What’s happened so far on Wednesday?
Mr. Trump opened the day by attacking Ms. Murkowski.
But Mr. Trump’s public shaming is not an effective strategy for Ms. Murkowski, who has dealt with worse from her party. In 2010, Ms. Murkowski retained her Senate seat in a historic win as a write-in candidate. She had lost Alaska’s Republican primary that year to a Tea Party challenger and was largely abandoned by Republican leadership. Since then, she has not felt beholden to her party.
Blue Cross Blue Shield warns the Senate
The Blue Cross Blue Shield Association warned senators on Wednesday that repealing the Affordable Care Act’s mandate that nearly everyone have health insurance would be disastrous if Congress fails to replace it with another measure that ensures that people get and maintain insurance coverage.
“If there is no longer a requirement for everyone to purchase coverage, it is critical that any legislation 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. Immediate funding for the cost-sharing reduction program also is essential to help those individuals most in need with their out-of-pocket costs, so they can access medical services. And dedicated funds must be provided to help pay for the care of those with significant medical conditions.In order to ensure a stable individual insurance marketplace, any final legislation must include these crucial elements to avoid steep premium increases and diminished choices that would make coverage unaffordable and inaccessible.”
The association appeared to be worried about a so-called “skinny repeal” bill that would do away with the Affordable Care Act’s individual mandate and mandate that most employers offer insurance to their workers, but would include little else. Republican leaders believe that such a narrow bill may be the only measure that can get through the Senate.
Now what happens in the Senate?
Senators are set to consider a different repeal measure on Wednesday.
This measure would repeal major parts of the health law but would not provide a replacement. The legislation resembles a bill that passed the Senate in 2015 but was vetoed by President Barack Obama in early 2016.
Senator Rand Paul, Republican of Kentucky, supports that approach. But some Republicans worry that repealing the law without providing a replacement would leave many Americans without health care coverage. Such a “repeal only” measure is not expected to garner enough votes for passage.
The vote for this measure had been expected to take place around midday Wednesday, but it has now been delayed until later in the afternoon.
Then what happens?
Republicans are using special budget rules to try to pass a repeal bill, so the debate is limited to 20 hours, and Democrats cannot delay it with a filibuster. Later this week, the Senate will hold what is known as a vote-a-rama, an exhausting marathon of amendment votes.
The nine Republicans who voted against the comprehensive replacement measure on Tuesday night are an indication of the problem that Senate Republican leaders continue to confront: The party caucus still does not agree on what should be in a health care repeal bill that would have enough support to win Senate approval.
One solution might be to pass a pared-down health plan that has support from at least 50 of the 52 Republican senators, and then turn to working out a compromise with the House.
Lisa Murkowski, a Swing Vote on Health Care, Isn’t Swayed
by Carl Hulse - NYT - July 26, 2017
WASHINGTON — Lisa Murkowski had heard enough.
As President Trump pressed her and her fellow Senate Republicans last week to fall in line behind a repeal of the Affordable Care Act in the interest of party loyalty and protecting the Republican brand, she felt compelled to speak up.
“With all due respect, Mr. President,” she said, according to some of the people at the private White House lunch, “I didn’t come here to represent the Republican Party. I am representing my constituents and the state of Alaska.”
Mr. Trump did not appreciate the pushback. Ms. Murkowski was one of just two members of her party to vote against a critical procedural step on Tuesday. Afterward, Mr. Trump voiced his displeasure on Twitter: “Senator @lisamurkowski of the Great State of Alaska really let the Republicans, and our country, down yesterday,” he wrote Wednesday morning. “Too bad!”
But it may be that it’s too bad for Mr. Trump, because he picked on someone unlikely to be rattled by his attack or by accusations that she deserted her fellow Republicans. Ms. Murkowski already survived a political near-death experience in 2010 when she lost a primary race to a Tea Partychallenger and was essentially abandoned by the Republican Party.
“She is unshakable when it comes to her constituents,” said Senator Susan Collins, Republican of Maine, the other Republican who opposed Tuesday’s procedural vote. “She has a spine of steel.”
Given the narrow 52-48 party divide in the Senate and the shrinking ranks of more moderate congressional Republicans, Ms. Murkowski has emerged as a key swing vote, giving her new influence. Nowhere has that been on display as much as in the health care fight.
Senator Mitch McConnell, the Kentucky Republican and majority leader, shaped his health care proposal with an eye toward Alaska, adding billions of dollars to help hold down insurance premium costs in a state where health care choices are very limited, as well as extra money for the care of native populations. Those provisions were added not only to woo Ms. Murkowski, but also to secure the vote of Dan Sullivan, the other senator from Alaska and a fellow Republican.
Ms. Murkowski remained leery of the health care proposal, expressing concern about its potential effects on the many Alaskans who rely on Medicaid, as well as the partisan manner in which it was being assembled behind closed doors by Republican leaders. Before the vote on Tuesday, she informed her colleagues she would break ranks.
“I’m very comfortable with the decision I made yesterday in working to advance Alaska’s interests,” Ms. Murkowski told reporters on Wednesday, adding that she doesn’t “really follow Twitter.”
Mr. Trump wasn’t the only irritated Republican. Representative Blake Farenthold, Republican of Texas, suggested that he might challenge the Senate Republican women opposing repeal to a duel, and a second House Republican, Representative Earl L. Carter of Georgia, on Wednesday issued a vulgar but incomprehensible insult.
Ms. Murkowski has already challenged Mr. Trump this year. She and Ms. Collins were the only two Republicans to oppose Betsy DeVos, Mr. Trump’s choice for education secretary, with Ms. Murkowski citing the nominee’s lack of experience in public education.
Ms. Collins said that as she and Ms. Murkowski, whose Senate desks are adjoining, prepared to turn their thumbs down on Tuesday, they discussed the possibility that the leadership might want to change their seating arrangement to keep them from being bad influences on each other.
Despite her position on the health care bill and her support for abortion rights, Ms. Murkowski remains a reliably Republican vote on most issues. An avid outdoorswoman, she draws regular criticism from Democrats and environmental activists for her support of the oil and gas industry — mainstays in her state — and the conservative stance she takes on other issues involving public lands and wildlife.
But in this case, Democrats credit her for a position they acknowledge must be difficult to maintain.
“I’m very impressed by what she is doing to try to get the right decision made,” said Senator Maria Cantwell of Washington, the senior Democrat on the Energy and Natural Resources Committee. “What she is trying to do is figure out how to preserve something that is so vital up there in her state.”
Ms. Cantwell, who has negotiated a bipartisan energy measure with Ms. Murkowski that could soon be acted on by the Senate, has traveled with her in Alaska. She said she had witnessed firsthand how truckers and fishermen have urged their senator to do what she could to maintain the health coverage they now rely on.
Ms. Murkowski’s vote on Tuesday made her the only Senate Republican who supported the repeal bill passed in 2015 to oppose moving ahead with the debate. She said circumstances in her state had changed significantly in the past two years.
Ms. Murkowski, who has little to no interest in national news coverage, carries a famous Alaskan name that has been an advantage and a hindrance. Her father, Frank Murkowski, was a four-term senator who left Congress in 2002 to run successfully for governor. After he was elected, he appointed his daughter Lisa, a state lawmaker, to his Senate post. Accusations of nepotism dogged her in her first campaign, in 2004, but she won — only to lose the Republican primary to Joe Miller, a Tea Party firebrand, six years later.
That 2010 defeat led national and state Republicans to pull support from her and caused some tension with her Senate colleagues, some of whom suggested she should be stripped of committee seniority. But her ultimate victory in the general election and the 2014 Republican takeover of the Senate seemed to smooth over any hard feelings. She has what is considered a decent working relationship with Mr. McConnell, though some colleagues occasionally bristle at her breakaway nature.
After Republicans met on Wednesday to plot their next move, Ms. Murkowski said she hoped the Senate could still find its way to a health care proposal she could support.
“I think there are areas we can identify that we can find common ground,” she said. “That is kind of the hope and desire, and I’m simply willing to start to find how we can get to that point.”
The limits of Ms. Murkowski’s independence may still be tested.
Welcome to the United States of Anarchy
by Dana Milbank - Washington Post - July 27, 2017
Welcome to the United States of Anarchy.
Health-care legislation languishes without presidential leadership. The Senate fails to pass a measure crafted by Majority Leader Mitch McConnell, fails to pass an outright repeal and even fails to pass a proposal to go back to the drawing board.
Huge majorities in Congress, declining to bless President Trump’s love affair with Vladimir Putin’s regime, vote for new sanctions against Russian officials; legislation passes the Senate, 98 to 2, and the House, 419 to 3. The veto-proof rebuke to the president seizes a foreign-policy function from an unreliable commander in chief.
As the deadline looms to avoid a default on U.S. debt, Susan Collins (R-Maine), a Senate committee chairman, is heard on a hot mic saying she’s “worried” about the president’s stability and calling his administration’s handling of spending matters “just incredibly irresponsible.” She says she doubts Trump even knows how the budget process works.
Trump, baffling and alarming allies, goes on the attack against his attorney general, Jeff Sessions, who was an outspoken supporter of Trump’s candidacy. Trump clearly wants Sessions to resign, but Sessions is ignoring him. Sessions’s former colleagues in the Senate back him over his boss — and they hope Trump isn’t crazy enough to start a crisis by firing Sessions and then special prosecutor Robert Mueller.
The Senate on July 26 voted against a proposal that would have ended major parts of the Affordable Care Act with a two-year delay to allow time for lawmakers to design new health-care legislation. (U.S. Senate)
Meanwhile, the president continues to sow chaos with perpetual distractions. He fires off a tweet Wednesday morning announcing he is banning transgender people from serving in the military. The tweet apparently catches even the Pentagon by surprise and draws rebukes from pro-military Republicans who argue that all able-bodied, patriotic Americans should be allowed to serve.
And the ship of state sails on, rudderless. This is what it might look like if there were no president at all: stuff happens, but nothing gets done. Actually, the majority in Congress has great difficulty even doing nothing.
McConnell and his team scheduled a vote on repealing Obamacare for 11:30 a.m. Wednesday — a proposal that was, by all accounts, destined for failure. But when the appointed hour came, Sen. Mike Enzi (R-Wyo.), sponsor of the repeal measure, requested a quorum call — a Senate procedure to stall for time.
Sen. Ron Wyden (D-Ore.) rose. “Mr. President, I think there was some confusion —” he began.
But Enzi objected, Wyden was forbidden to speak, and the quorum call resumed — for 43 silent minutes.
Senators arrived for the scheduled pre-lunch vote. Sen. Bob Corker (R-Tenn.) went to the clerk’s table to give a thumbs up and Sen. Heidi Heitkamp (D-N.D.) went to give a thumbs down, and both were told the same thing: “We’re not voting.” Senators milled about the chamber and huddled in clusters while aides and Senate leaders came and went to resolve the impasse, an arcane dispute about points of order and procedures for amendments.
Finally, Enzi spoke: The vote would be postponed for four more hours.
The Sisyphean act, all for a proposal that was going nowhere, encapsulated the whole Dada enterprise of health-care legislation. McConnell, thwarted in his quest to round up votes for the House-passed version of Trumpcare, or for his own Trumpcare alternative, or even for a repeal of Obamacare without a replacement, decided instead to risk everything on a “motion to proceed” — a parliamentary maneuver that allows debate to begin.
McConnell won that vote Tuesday by the thinnest possible margin, a 50-50 tie, broken by Vice President Pence. But then McConnell was the proverbial dog that caught the car. Hours later, he brought up his health-care legislation, and it went down, 43 to 57, losing nine of his fellow Republicans and falling 17 votes short of what he needed.
On Wednesday came Enzi’s repeal proposal, which wouldn’t have taken effect for two years to buy lawmakers more time to draft an Obamacare replacement. After the four-hour delay, it went down, 45 to 55, with seven Republicans defecting. Senators then voted down, on party lines, a Democratic proposal to send the whole thing back to committee.
Republicans, after complaining for years that they had been jammed by Democrats on the passage of Obamacare, brought their alternative forward in a secretive, rushed, Republican-only process without hearings. Far from giving lawmakers time to “read the bill,” GOP Senate leaders had them vote to begin debate without knowing which legislation they would be debating.
Soon comes a vote on “skinny repeal,” which, if it became law, would sabotage Obamacare by eliminating individual and employer requirements to provide health insurance. But it won’t become law; it would merely become an excuse for more negotiations that would pit Senate GOP moderates against House GOP conservatives.
So it goes when a president doesn’t act like one: all fury, no function.
Harvard Pilgrim reduces Maine rate-hike request for 2018
by J. Craig Anderson - Portland Press Herald - July 25, 2017
Harvard Pilgrim Health Care has reduced its average rate increase request for individual Affordable Care Act insurance plans from the previously announced 39.7 percent to 29.2 percent.
The provider said during a rate hearing Tuesday before the state Bureau of Insurance that it has recalculated its request for 2018 using previously unavailable data from the first quarter of 2017, which showed more positive activity regarding revenue and expenses.
Harvard Pilgrim still is seeking the largest annual rate increase of Maine’s three ACA insurers. Maine Community Health Options is requesting a 19.7 percent increase, and Anthem Blue Cross and Blue Shield is asking for a 21.2 percent increase.
In testimony before a seven-member panel led by state Superintendent of Insurance Eric Cioppa, Harvard Pilgrim Maine Vice President Edward Kane said the provider acquired a relatively expensive group of Maine policyholders in 2016, partly because competitor Community Health suspended new memberships that year.
During that period, Kane said in pre-filed written testimony, those who signed up through special enrollment with Harvard Pilgrim “tended toward higher claims costs and more frequent lapses in coverage than those enrolled during the annual open enrollment period.”
However, Community Health has resumed taking on new members, so special enrollment members have been more evenly distributed among the three carriers in 2017, he said. Harvard Pilgrim representatives explained that people can sign up partway through the year via special enrollment if they’ve experienced a life-changing event such as job loss or a divorce. Such members might undergo an expensive medical procedure while they have coverage, and then decide not to renew during the open enrollment period the following winter.
That failure-to-renew risk is greater since the Internal Revenue Service has begun accepting tax returns that do not include proof of health insurance, Kane said. Such proof had been required under the ACA.
“This action, taken in response to the president’s executive order directing federal agencies to provide potential relief from aspects of the ACA, leaves consumers with the perception that the individual mandate penalty will not be enforced,” Kane said. “Consequently, we have already seen evidence of a shrinking individual market.”
In general, lack of enforcement of the ACA’s individual mandate penalty is expected to lead to fewer young and healthy Maine residents participating in the ACA, which would increase ACA insurance costs for the remaining enrollees, he said.
UNCERTAINTY AFFECTS RATES
Maine Assistant Attorney General Tina Moylan, who represented consumers during the hearing, asked Harvard Pilgrim representatives several probing questions about the assumptions they used to arrive at their 29.2 percent increase request, as did members of the panel.
One question was how Harvard Pilgrim knows that not enforcing the mandate would lead to a smaller and sicker pool of insured in Maine. The insurer’s actuaries acknowledged that they don’t have specific data on why former ACA members have dropped their coverage.
The panel also asked Harvard Pilgrim for more information about an “alternative” rate request provided to the Bureau of Insurance that indicates which rates it would seek to change if the Republican-controlled Congress eliminates cost-sharing subsidies that help lower-income policyholders cover costs. The bureau asked all three ACA providers to submit alternative requests.
Harvard Pilgrim’s alternative request is for an average rate increase of 39 percent above 2017 rates if the subsidies are eliminated, similar to Community Health’s anticipated 40 percent rate increase for its silver plans if the subsidies end. Anthem has told the bureau that it would withdraw from the Maine ACA marketplace entirely if the subsidies are eliminated.
Finally, the panel asked whether Harvard Pilgrim intends to remain in Maine’s ACA marketplace after 2018.
“Right now the company has not made a decision as to staying in the market after next year,” Kane said. “It is not decided.”
THE VIEWS OF POLICYHOLDERS
At the hearing, Harvard Pilgrim policyholder Kimberly Flood of Brunswick asked the panel to grant the insurer’s rate request. Superintendent Cioppa must make his decision by the federal deadline of Aug. 16.
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“They have never denied me anything,” said Flood, a recent cancer survivor. “This is a special company. I think we’ve got to work with them to keep them in the state.”
But Harvard Pilgrim policyholder Nancy Linkin of Camden, who is receiving treatment for breast cancer, said the fear of a significant premium increase has made it difficult to sleep at night.
“I rescheduled my chemo treatment and came here to tell my story,” Linkin said. “I am absolutely terrified.”
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