<p>Despite his best efforts, Senate Majority Leader McConnell couldn’t coax a ‘yes’ vote out of 50 of his 52-member caucus before the July Fourth recess. The path forward for McConnell and the Senate Republicans seems to revolve around trying to move in two directions at once – more money for the more centrist party members coupled with more insurance deregulation for the far-right — while continuing to mislead the public about the true content of the bill.<br /> <br /> Here’s a closer look at why the Senate bill stalled and what steps are being taken to revive it, along with some notable bits and pieces from the recent debate.</p>
<h3><strong>Why McConnell couldn’t get to ‘yes’ before the Fourth</strong></h3>
<p>The push for a vote before the Fourth ran aground on a combination of internal Senate dynamics and external forces. As far as internal dynamics go, roughly three groups of senators blocked the path to a Senate vote. One group, typified by senators <a href=Heller and Collins, expressed concerns about the damage the legislation would do to the health care system in their states; Other senators, Such as Ron Johnson from Wisconsin, were unhappy with the process and wanted more time to evaluate the bill. Finally, senators like Ted Cruz and Rand Paul did not believe that the bill did enough to roll back the ACA or to undermine the Medicaid program. Key external forces were also critical in giving senators pause. Especially important were the popular mobilization against the bill, as well as the rising tide of stakeholder opposition. Absent these external forces, there is little doubt that the Senate would have swallowed its doubts and voted.

Where does the bill go from here?

In order to win over wavering moderates, one possible option being debated is to dial back on some of the tax cuts in the bill. For example, some senators seem to support abandoning at least some the tax cut for wealthy individuals (while keeping the cuts that affect the health care industry). This would restore about $170 billion in revenue. Adding this amount to the $188 billion they already have in hand to spread around (the difference between the House’s deficit-reduction score which they have to meet, and the score of Senate bill), they could attempt to win over some of the holdouts. The problem is that the Senate bill cuts around $1.2 trillion from the health benefits of low- and moderate-income people. Putting back less than one-third of that amount still leaves a bill with deep, devastating cuts (that fall hardest on communities that voted for Trump, by the way) – still a mean bill by any estimation – while also potentially losing votes on the far right in both the Senate and, ultimately, the House.
Another route Senate Republicans may attempt is to double down on their efforts to improve the optics of their bill without actually making it any better. For example, thanks to various efforts to undermine the functioning of the ACA, there has already been a decline in the number of people covered since Trump took office. Some senators have come up with a novel tactic: asking the CBO to change the base year on which they calculate coverage losses from 2016 – as has been used through the House legislative process and to date – to January 2017, so that the coverage loss numbers would “look” smaller, even though the number of people without insurance would be exactly the same. Of course, it was the Republican-controlled Budget Committee that picked 2016 as the base year to begin with and even many conservatives have already come out and criticized this effort to “cook the books.” Moreover, given CBO’s customary aim to compare “apples to apples,” they are unlikely to make this base year change, so the success of this gambit is highly doubtful.

In addition, they already have tried this with without success with respect to their approach to Medicaid – the more gradual elimination of Medicaid expansion funding in the Senate compared to the House’s still lands us at exactly the same place as the House bill, just on a slightly different timeline. The Senate also tried to hide their even more draconian Medicaid cut by having it not take effect until the end of the CBO’s standard 10-year analysis window. But the CBO wasn’t having it and released a follow up analysis on June 29 (thanks to a request from Senator Wyden) showing that Medicaid would be cut by over a one-third as a result of the Senate bill. As the National Association of Medicaid Directors noted in its statement, no possible degree of administrative flexibility could compensate for this magnitude of cuts. Rates, services and eligibility would all have to be drastically curtailed, with severe consequences not only for beneficiaries but for major parts of the health care system. Providers are now figuring that out, as evidenced by the recent uptick in engagement by groups such as the nursing home industry which had previously been sitting on the sidelines.
Finally, the Senate is considering an amendment that would recreate an alternative insurance market without vital consumer protections the ACA affords, such as minimum benefit requirements and the ban on charging sick people higher rates. This would be a disaster that would almost immediately turn the plans offered on the Exchanges into a high-risk pool with premiums that would be unaffordable for anyone who didn’t qualify for significant financial assistance.

Forget what he said yesterday

“Repeal now, replace later,” (maybe) may be making a comeback?  Trump is calling for a straight repeal with no replacement if the Senate can’t agree on a replace strategy. While the president may have forgotten (or simply doesn’t care) that he panned this strategy just a few months ago, there is a reason the idea was rejected. A straight repeal bill has a devastating effect on the number of people insured and on the health care industry.
Ironically, of course the “replace bills” offered by each chamber haven’t been much better than straight repeal. That’s because the essence of “straight repeal” is to eliminate the ACA revenue streams and pay for that lost revenue by cutting benefits. Each iteration of the bill has preserved this core mechanism and so each one causes large coverage losses and economic harm to providers and states. Therefore, the same logic that led to the rejection of “repeal without replace” should lead to rejection of any of the replacement options offered so far. (Of course, the role of logic in this debate is severely constrained.)
More ironically, the replace bills actually do more damage to Medicaid beneficiaries than does a straight up repeal. Both a straight repeal and the replacement plans end the enhanced financing for the Medicaid expansion, but the replacement bills go further and cut coverage for children, people with disabilities and older adults. Some Republicans have tried to defend their Medicaid cuts by claiming they are needed to control the federal deficit. The fact that most of the Medicaid cuts are used to pay for tax cuts rather than deficit reduction reveals the utter hollowness of this claim.

Looking ahead

If  McConnell thought there was no chance of getting to ‘yes,’ he would have brought up the bill already in order to clear the decks for other business. We can, therefore, be pretty certain that the Senate will take another run at passage in the next couple of weeks. But time is running out on repeal (not as a procedural matter, but as a practical one for GOP leadership). There is a crowded congressional calendar with tax reform, raising the debt ceiling and 2018 appropriations all on tap. Some senators have already called for shortening or canceling the August recess to address the pile up. Trump’s attempt to revive repeal without replace smacks of desperation. All in all, this means the next several weeks a critical make or break point. Blocking the repeal effort now won’t make the problems in the health care system go away, but it will substantially change the starting place from which we can address those problems.

Bits and Pieces…

When too much is not enough
Sheldon Adelson seems pretty unhappy with Senator Heller and it’s no wonder. If BCRA passes, the Nevada billionaire gets a $48 million per-year tax cut (and lord knows he needs another $48 million), so Heller’s opposition to the law based on the cuts it would impose on people on Medicaid and who lack ESI was a blow. Does seem like a tough call, doesn’t it? – tax breaks for billionaires or health care for kids, seniors and people with disabilities – but Sen. Heller seems to have figured it out (at least for now). Let’s hope more of his colleagues reach the same conclusion.

They just don’t get it

It is simply mind blowing that “men shouldn’t have to pay for maternity care” remains a talking point among those pushing to scrap the Essential Health Benefits (EHB) protection in the ACA. It seems like people making this argument don’t understand the principle of risk-sharing that is essential to any insurance market. Further, it seems like an obvious national priority to ensure that the next generation gets a healthy start and has fewest possible medical complications at birth. Yes, this could be achieved with a universal program covering maternity care and delivery, but that is not what opponents of EHB are advocating. Instead, they are simply proposing that men be exempt from sharing the cost of maternity care. Which leads me to speculate that, in addition to being unclear on how insurance works, they are also unclear on the “facts of life.” Someone needs to sit them down for a little talk – “no, the stork didn’t bring you.”

With thanks to Quynh Chi Nguyen, policy analyst, for her assistance.