The Health 202: Senate is straining to pass Obamacare overhaul in next 14 days

THE PROGNOSIS

The Senate GOP leadership is trying to rally enough steam to vote on an Obamacare overhaul in the 14 days left in June. But potential roadblocks are piling up both publicly and behind-the-scenes that could easily derail its efforts. 

For one thing, the Congressional Budget Office would need time to score final legislation. And the parliamentarian would need to give the thumbs-up to its individual parts. Which leads us to the biggest reason a vote this month is possible but very, very hard: Republicans don’t even have a bill yet.

“Join the crowd, I’m in the same category,” Senate Finance Chairman Orrin G. Hatch told (Utah) a reporter yesterday who complained that they don’t know the details of the health-care plan Senate Majority Leader Mitch McConnell (R-Ky.) is cooking up in time for the July 4 recess (read more on McConnell’s calculations here). 

Bloomberg’s Sahil Kapur documented the Hatch moment on Twitter:

Going into the week, Republicans had high hopes they’d be able to rally quickly around a bill. McConnell presented a range of options to members during a lunch on Tuesday. The same day, a dozen or so Republicans shared a meal with President Trump to discuss the efforts. Senators are feeling heavy pressure to move an Obamacare revamp quickly before August recess hits and the whole, complicated effort becomes even harder.

“Impassioned policy disputes have flared among some GOP senators in large group meetings at which McConnell has floated ideas from the drafting process,” my colleagues Kelsey Snell and Sean Sullivan report. “But those disputes have not deterred him from the goal of a floor vote before the July 4 recess, said the Republicans familiar with the process, who spoke on the condition of anonymity to talk candidly about private conversations.”

McConnell and Co. hedged their aggressive timeline in public this week. But, as McConnell sees it, the policy options have all been vetted. “Now, the difficult decisions about what to put in and leave out of the final bill are all that remain,” Kelsey and Sean write.

But those decisions might be more than difficult — they might be fatal to the possibility of passing a health-care bill at all. The more candid senators readily admitted this week that divisions persist.

“We’ve got a divided caucus,” Sen. John McCain (R-Ariz.) told reporters this week. “I listen avidly at lunch as we go over the same arguments over and over and over again.”

Health and Human Services Secretary Tom Price admitted yesterday that he hasn’t seen what Republicans are working on, even though his staff has provided technical assistance. “I haven’t seen any legislative language,” Price told the Senate Appropriations Subcommittee on Labor, Health and Human Services, Education and Related Agencies. 

Matt House, communications director for Senate Minority Leader Charles E. Schumer (D-N.Y.), noted Price’s comments at the hearing:

The 52 Senate Republicans must work as a pack if they ever want to pass a health-care bill with a simple majority (and a likely tie-breaking vote from Vice President Pence). Only two of them can roam free. At this point, it’s a given that libertarian-leaning Sen. Rand Paul of Kentucky will be one of the free-rangers. Yesterday, Paul all but said he’d vote against the bill, criticizing its likely inclusion of a refundable tax credit to subsidize private insurance.

“I think we shouldn’t have new entitlements that will go on forever in a Republican plan to fix health care,” Paul told reporters. “We can’t pay for what we already have: Medicare, Medicaid and Social Security.”

Assuming Paul’s out of the picture, the question then is who the other defector would be. Many have viewed Sen. Susan Collins (R-Maine) as the most likely moderate to buck her party. But Sen. Lisa Murkowski (R-Alaska) is also a strong possibility after comments she made to Vox’s Dylan Scott. “I want greater access and lower costs,” Murkowski said. “So far, I’m not seeing that happen.”

And as members continue to debate amongst how much of the Affordable Care Act they should try to repeal and the breadth of insurance subsidies to enact in its place, things are also getting privately contentious.

Democrats and Republican on the Budget Committee are still at odds over whether the Senate can even use the budget reconciliation bill sent over from the House. Republicans say it’s got the green light, while Democrats are still contending that the parliamentarian could rule the whole thing out of order.

And then there’s the sticky question of whether individual components of the House bill can pass what’s known as the “Byrd rule” governing what can fit within a budget bill. Democrats and Republicans must meet to argue their case before the parliamentarian, but that meeting hasn’t even occurred yet. The outcome holds big ramifications for what the Senate can include in its legislation.

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“There have been no bipartisan meetings or decisions from the parliamentarian on Bryd Rule issues yet,” a spokesman for Budget Democrats told The Health 202.

To be fair, a June vote on a health-care measure isn’t out of the realm of possibility. But the window is closing fast. And if Senate Republicans don’t wrap up their efforts to produce legislative text and get a CBO score until July, that leaves limited time to reconcile a bill with the House before August recess.

So pour yourself a mojito and get ready for Summer of Obamacare Repeal Drama. It could be long and twisty.

SHOOTING UPDATE: 

–House Majority Whip Steve Scalise (R-La.) remains in critical condition as of Thursday evening but has improved since Wednesday, according to MedStar Washington Health Center. Lobbyist Matt Mika’s condition, previously critical, has improved to serious, according to George Washington University Hospital.

–Just more than 36 hours after the shooting that left Scalise and five others injured, Republican and Democratic lawmakers bowed their heads in prayer in the middle of the field at Nationals Park, at the Congressional Baseball Game that carried on in a show of unity and bipartisanship in front of a record crowd of 24,959. Special agent David Bailey, one of the Capitol Police officers injured in the shooting, threw out the first pitch.

–House Speaker Paul D. Ryan (R-Wisc.) and House Minority Leader Nancy Pelosi (D-Calif.) gave a joint interview to CNN from the game. “Tonight we’re all Team Scalise,” Pelosi said. Ryan called for unity and a for toning down heightened rhetoric in the wake of the shooting. “What we’re trying to do is tone down the rhetoric, lead by example and show people we can disagree with one another, we can have different ideas without being vitriolic, without going to such extremes,” he said. While the Democrats won the baseball game 11-2, they gave the trophy to Republicans to give to Scalise.

AHH, OOF and OUCH

AHH: Drug stocks dropped suddenly yesterday after a Bloomberg report that the Trump administration is preparing an executive order aimed at lowering U.S. drug costs. Trump hammered on high drug prices during his campaign, but has said little publicly about the issue since then.

“Top health and budget officials in the administration will meet Friday to discuss the issue, according to the people, who asked not to be identified because the session is private,” Bloomberg’s Anna Edney and Justin Sink report. “One policy being discussed for inclusion in the order is expressing support for value-based agreements, a drug industry-backed proposal in which pharmaceutical companies and health insurers develop arrangements to pay for products depending on how well they work, one of the people said.”

OOF: An estimated five percent of the population accounts for 50 percent of total medical costs, The Atlantic reports, in an article exploring how the U.S. spends $3.4 trillion on medical care every year. “That’s about 18 percent of the country’s total GDP, meaning that one out of every six dollars we spent in 2016 went to health care,” T.R. Reid writes. “The national doctor bill dwarfs anything else we spend money on, including food, clothing, housing, or even our mighty military.”

“If that $3.4 trillion were spread equally throughout the population, the bill would come to some $10,350 for every man, woman and child in the country,” T.R. continues. “But fortunately –for most of us, anyway—the cost of health care is not equally distributed. Rather, a small number of Americans run up most of the expense. The biggest medical costs are concentrated on a fairly small segment of the population—people with one or more chronic illnesses, plus victims of accidents or violent crime.”

OUCH: Will the Senate’s health-care strategy of moving forward behind closed doors without committee hearings backfire? Maybe not. But then again, maybe.

“The bill’s secrecy is garnering more and more attention, and more and more outrage,” Paul Waldman writes in an opinion piece for the Post. “It has become one of the leading complaints Democrats make about it. And as any marketer knows, suspense is a terrific tool to increase public interest in your product. Tell people that your new movie or album is coming out soon, but give them only a taste of what it contains, and you’ll heighten the anticipation.”

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“So by the time we actually get a look at the Senate’s bill, all that waiting may have primed the media to give it a great deal of attention, primed Democratic officeholders to run to the cameras to denounce it, and primed liberal activists to mount an all-out assault on the bill, pressuring potentially wavering senators to oppose it,” Paul writes.

HEALTH ON THE HILL

–Outrage is growing at the secrecy of Senate Republicans as they write a health-care bill. Even the rank-and-file are starting to acknowledge the process is unfolding in a less-than-ideal way. 

“I’ve said from Day 1, and I’ll say it again,” said Senator Bob Corker (R-Tenn.) told the New York Times. “The process is better if you do it in public, and that people get buy-in along the way and understand what’s going on. Obviously, that’s not the route that is being taken.”

Sen. Ron Johnson (R-Wis.) indicated similar frustration to the NYT. “I come from a manufacturing background,” Johnson. “I’ve solved a lot of problems. It starts with information. Seems like around here, the last step is getting information, which doesn’t seem to be necessarily the most effective process.”

Last week, The Health 202 wrote about how Senate Republicans are falling even shorter of transparency than Democrats did back in 2010. And two great health reporters, Vox’s Sarah Kliff and Kaiser Health News’s Julie Rovner, gave their perspective from years of covering health policy on Republicans’ descent into secrecy.

Vox’s Carlos Maza tweeted that it’s against democratic values:

Priorities USA, the largest Democratic super PAC, said it’s no surprise Republicans are acting this way:

–Meanwhile, there was a larger crowd than I’d ever seen before at theCcongressional baseball game last night. A fierce McConnell/Pelosi/Schumer/Ryan foursome yelled “play ball” to kick off the game:

Regarding Scalise, MedStar Washington Health Center earlier announced that the rifle shot to Scalise’s left hip “traveled across his pelvis, fracturing bones, injuring internal organs, and causing severe bleeding.” He went into shock and within hours received many units of blood via transfusion and underwent two operations. The Post’s Lenny Bernstein explores how a single penetrating wound to the pelvic region, which is densely packed with blood vessels, organs and other structures, is extremely dangerous. 

“Such details reflect the complexity of the pelvic area, which is home to the iliac blood vessels that include major arteries branching off the aorta — the main route that carries oxygenated blood to all parts of the body,” Lenny writes. “Wounds to those vessels, large and small, cause fast, severe blood loss, which can set off a cascade of problems for surgeons trying to save a patient’s life.”

“In fact, 30 percent to 50 percent of injuries to the main iliac vessels result in death, said Joseph V. Sakran, director of emergency general surgery at Johns Hopkins Hospital, who was himself shot in the throat after a football game about two decades ago when a fight broke out and someone fired into the crowd.”

–Get ready to hear about President Trump’s offline depiction of the House GOP health-care bill as “mean” for months on end. Democrats are certain to hammer that comment, which the president made to senators during a White House lunch earlier this week as he pushed them to make their bill more generous. The Democratic Senatorial Campaign Committee is using it to target several House members considering Senate runs next year, including Pennsylvania Reps. Mike Kelly (R) and Lou Barletta (R) who might challenge Sen. Bob Casey (D).

“It’s a rare moment when we agree with Donald Trump, but he’s right: Congressmen Kelly and Barletta’s health care plan would increase premiums by 20 percent, slash coverage for preexisting conditions and impose an age tax that would make older Pennsylvanians pay five times more for care — all to give big insurance companies another taxpayer funded handout,” DSCC spokesman David Bergstein said in a news release.

MALPRACTICE

–Trump lobbed some sharp criticisms at the ACA as he hosted lunch on Tuesday for more than a dozen Republican senators to discuss their repeal-and-replace efforts, charging that premiums are skyrocketing out of control and millions are dropping out of the marketplaces. Post fact-checker Glenn Kessler dug into these claims — and found that Trump mangled things a bit. Let’s take it statement by statement: 

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What Trump said: “Americans were told that premiums would go down by $2,500 per year. And instead, their premiums went up to levels that nobody thought even possible.”

The facts: “Obama, when campaigning in 2008, did misleadingly say that his plan would reduce premiums for families by $2,500,” Glenn writes. “Over the years, Republicans have compared this misguided Obama pledge with the increase in annual family premiums for employer-provided plans, even though the ACA largely was aimed at the individual insurance market.”

“But here’s the funny thing: Health costs for employer-provided plans have grown much slower than expected since the Affordable Care Act was implemented. Experts debate whether the ACA played a significant role, but the average family premium is now almost $3,600 lower than if premium growth had kept pace with the rate in the decade before the law was passed.”

As for marketplace coverage, it’s hard to compare pre-ACA plans with post-ACA plans because the law eliminated plans with low costs but few benefits. “One study found that, when adjusting for actuarial value to create an apples-to-apples comparison, individual-market premiums actually dropped after the introduction of the ACA,” Glenn writes.

“Average insurance premiums in the Obamacare marketplace now are about at the level predicted by the Congressional Budget Office for 2017 when it first evaluated the law in 2009,” he writes. “But premiums have certainly spiked in recent years, as insurance companies grappled with a mix of people in the insurance pools tilted toward people who have chronic illnesses and thus require more care and frequent doctor or hospital visits.

What Trump said: “It was just announced yesterday that 2 million people have dropped out of Obamacare — 2 million additional. They are leaving fast….Insurers are fleeing the market…Last week it was announced that one of the largest insurers is pulling out of Ohio — the great state of Ohio.”

The facts: An HHS report last week said that 10.3 million marketplace enrollees paid their first premium in February, compared with 12.2 million who had signed up for coverage as of Jan. 31. But the report tracked payments only through mid-March, even though many people don’t pay their first month’s premium until that month. And for all past enrollment periods, there have always been a certain percentage of customers who don’t end up paying their premium at all.

As for insurers fleeing the market, it’s true that many are pulling out, but Trump ignores that many say they’re exiting the business because of uncertainty created by his own administration — in particular, whether it will continue to pay “cost-sharing reductions” to insurance companies helping them reduce co-pays and deductibles for low-income patients.

“Trump specifically mentioned Ohio. But Anthem Insurance, saying it would leave the state’s exchange, cited the lack of certainty about the cost-sharing payments and ‘an increasing lack of overall predictability,'” Glenn writes. “So Trump, decrying the ‘broken promise’ represented by the departure of insurance companies, blames Obamacare for problems that his administration has fostered.”

INDUSTRY RX

STATE SCAN

DAYBOOK

Today

  • OMB Director Mick Mulvaney will chair a meeting with top administration officials today to talk about a forthcoming executive order that would target lowering drug costs in the United States, according to reports by Politico and Bloomberg.

Coming Up

  • The Senate Appropriations Subcommittee on Agriculture, Rural Development, Food and Drug Administration will hold a hearing on the FDA’s budget request with FDA commissioner Scott Gottlieb on June 20.
  • The Senate Appropriations Subcommittee on Labor, Health and Human Services, Education and Related Agencies will hold a budget hearing for the National Institutes of Health on June 22.

 

SUGAR RUSH

House Minority Leader Nancy Pelosi (D-Calif.) criticized Senate Republicans for writing their version of the American Health Care Act behind closed doors:

President Trump bashes Obamacare, claims Americans are “fleeing the market:”

Here are five things to know about youth tobacco use, according to the CDC:

Watch as Republicans and Democrats pray together at the Congressional Baseball Game: 

And Stephen Colbert takes on the report from The Post that special counsel is investigating President Trump for possible obstruction of justice:

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