Tough decisions loom for Dems on ObamaCare

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Congressional Democrats have to decide how badly they want an ObamaCare deal.

Senate Republicans are open to renewing the insurer payments that President Trump canceled last week, but, in return, they want to expand a program that allows states to waive Affordable Care Act regulations.

That asking price could be hard for Democrats to swallow.

While Democrats want to protect ObamaCare, they fear that expanding the waivers would allow states to chip away at the bedrock protections of the law, including the rules on what an insurance plan must cover.

The politics of the health-care debate are also shifting.

While ObamaCare used to be a liability for Democrats, a Kaiser Family Foundation poll in August found that 60 percent of respondents think Republicans are responsible for problems in the Affordable Care Act going forward. Only 28 percent said the responsibility rests with Democrats.

Polls like that make some Republicans nervous about an ObamaCare backlash in the 2018 elections. And Democrats, hopeful of winning back the House and potentially even the Senate next year, are eager to hang ObamaCare’s problems around the GOP’s neck.

“Republicans in the House and Senate now own the health-care system in this country from top to bottom, and their destructive actions, and the actions of the president, are going to fall on their backs,” Senate Minority Leader Charles Schumer (D-N.Y.) said on Friday.

Negotiations over an ObamaCare bill have been going on for weeks, with Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) seeking an agreement to stabilize the markets and protect people’s coverage options.

Democrats say they are pushing for a deal, and Murray said Friday she was “optimistic” that one could be reached.

Trump’s decision to cancel the payments to insurers added fresh urgency to the talks. Health-care experts warn the loss of the payments — meant to offset the cost of insuring some lower-income people — could cause insurers to flee the system before open enrollment begins Nov. 1.

Several Republicans have said they are worried their constituents will be hurt by a collapse of the marketplaces, seemingly bolstering the talks.

But it’s far from clear that any ObamaCare deal reached by the Senate can become law.

Speaker Paul Ryan (R-Wis.) said last month that an Alexander-Murray deal is “not viable” for the House GOP.

And Trump on Monday sent mixed signals about whether he’d be willing to sign a bill reviving the ObamaCare payments.

The president declared that ObamaCare is “dead” and boasted that he had ended the “gravy train” of payments to insurers, causing their stock prices to drop.

“Hundreds of millions of dollars a month handed to the insurance companies for very little reason, believe me. I want the money to go to the people. … I want the money to go to people that need proper health care, not to insurance companies, which is where it’s going as of last week. I ended that,” he said.

Yet Trump also seemed to endorse the Alexander-Murray talks, stating that the two parties are “meeting right now and right now they’re working on something very special.”

“I do believe we’ll have a short-term fix because I think the Democrats will be blamed for the mess. This is an ObamaCare mess,” he said.

Sen. Lindsey Graham (R-S.C.), who golfed with Trump over the weekend, said on CBS on Sunday that Trump had spoken with Alexander and that Trump is open to a deal to continue the cost-sharing reduction payments if there is enough flexibility for the states.

“We are willing to work with Congress  to reach a legislative solution,” a White House aide said. “We will not provide bailouts to insurance companies until we provide the American people with relief from the ObamaCare disaster.”

Schumer said  on Monday in a written statement that he welcomes Trump’s support for a deal.

“I’m hopeful that we are nearing an agreement that makes clear that we have no intention of supporting the president’s efforts at sabotage,” he said. “If he’s now supportive of an agreement that stabilizes and improves the existing system under the Affordable Care Act, we certainly welcome that change of heart.”

The negotiations have been hung up on the question of how far to go in waiving ObamaCare’s regulations.

Republicans say it is not enough to speed up the process for a state to get a waiver; instead, the scope of the waivers must be broadened.

Alexander says he has agreed to fund two years of the ObamaCare payments, known as cost-sharing reductions, which is more than his original offer of one year. He says Democrats need to give up something in return.

Democrats argue that they have already made significant concessions, including agreeing to expand low-cost “copper” health insurance plans, streamlining the waiver process by letting states choose from a “menu” of options and allowing insurers to charge higher out-of-pocket costs for some services.

Asked Monday if he wanted more flexibility for states than Democrats are willing to give, Alexander replied, “I want as much as we can get.”

“I mean, I would like to repeal and replace ObamaCare, and Sen. Murray would like to keep it intact, but that’s not how you make a compromise,” he said.

Alexander said Trump has encouraged him to make a deal, as has Schumer.

“I find that very encouraging, that both the president and Sen. Schumer encouraged me to do something,” Alexander said.

Still, he declined to put any timetable on when an agreement could be reached.

What the FY 2018 budget resolution means for ACA repeal

The Senate side of the United States Capitol in Washington, D.C.

Senate Republicans’ fiscal year 2018 budget resolution suggests that they have put their goal of broadly unwinding the Affordable Care Act on the back burner—yet they could still use it to repeal key parts of the law.

The budget resolution (PDF), released by Senate Budget Committee Chairman Mike Enzi, R-Wyo., on Friday, contains reconciliation instructions that direct the Senate Finance Committee to “reduce revenues and change outlays to increase the deficit by not more than $1.5 trillion over the next 10 years.”

Since that reconciliation instruction is rather broad, the GOP could potentially use it to repeal some ACA-related taxes and other provisions that make health insurance affordable under the law, argued a post from the left-leaning Center for American Progress (CAP).

With their new budget resolution, Republicans could also still roll back other portions of the ACA, including the individual mandate, a Bloomberg article noted.

But because the budget resolution doesn’t include any instructions for the Senate Health, Education, Labor and Pensions Committee or the House Energy and Commerce Committee to craft reconciliation legislation, that may indicate that broader ACA repeal efforts are on hold, The Hill reported.

In addition to the reconciliation instructions, the budget resolution includes deficit-neutral reserve funds for legislation that would allow Congress to repeal or replace the ACA. This primarily just signals rhetorical support for rolling back the healthcare law, the CAP post noted, but that’s significant since it shows the GOP isn’t giving up on repeal.

Senate Budget Won’t Let GOP Pursue Full Obamacare Repeal

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Senate Republicans unveiled a fiscal 2018 budget resolution Friday that they intend to use to push through as much as $1.5 trillion of tax cuts in the coming months, but it won’t allow the GOP to pursue a full repeal of Obamacare.

The budget proposal would still allow Republicans to pursue a much narrower attack on the Affordable Care Act, including repealing the individual mandate to purchase coverage. The resolution also would let the GOP use the fast-track process to open up drilling in the Arctic National Wildlife Refuge.

The budget, authored by Senate Budget Chairman Mike Enzi, forecasts a balance in nine years through $5 trillion in largely unspecified spending cuts. Unlike the House budget proposed in July, Enzi’s blueprint doesn’t call for cuts to Medicaid or a partial privatization of Medicare.

“A pro-growth tax plan will move the U.S. economy forward and help to produce better jobs and bigger paychecks for every American,” Enzi, of Wyoming, said in an emailed statement.

The Senate draft is to be voted on by the Budget Committee next week, with floor votes planned later in October and a conference to resolve differences with the House after that. The House plans a floor vote on its budget plan next week.

Tax Cut

Once in place, the budget resolution would allow Republicans to bring up a tax-cut bill that would increase deficits by as much as $1.5 trillion, compared with a Congressional Budget Office baseline. Under the fast-track process, the GOP-controlled Senate could pass the proposal with no Democratic votes.

The budget sets a target for the Senate Finance to report back with its draft tax bill by Nov. 13.

“The Senate budget resolution drafted by Budget Committee Chairman Mike Enzi is a critical step to advance President Trump’s agenda to provide tax relief for the middle-class and unleash economic prosperity for all Americans,” said White House budget director Mick Mulvaney in a statement. “I urge the Senate to pass this resolution and come to a swift agreement with the House so President Trump can sign America-first tax relief into law this year.”

Senate Democratic leader Chuck Schumer of New York said the GOP plan would “blow a huge hole in the deficit and stack up debt, leading to cuts in programs that middle-class Americans rely on.”

Individual Tax Rate

President Donald Trump and Republican leaders announced a tax-cut plan Wednesday that would cut the top individual rate to 35 percent from the current 39.6 percent. It would let Congress decide whether to create a higher bracket for those at the top of the income scale. The rate on corporations would be set at 20 percent, down from the current 35 percent. Under Senate rules, any tax cuts that increase the deficit would have to expire in 10 years because the budget process can’t be used for long-term deficit increases.

The provision making it easier for Congress to allow oil and gas drilling in part of the Arctic National Wildlife Refuge was sought by Alaska Republican Dan Sullivan. Under the proposal, royalties from oil and gas production in the wildlife refuge would be raise revenue that could help offset at least $1 billion in tax cuts over a decade.

The proposal’s instructions to the Finance Committee could allow a partial repeal of Obamacare, although panel Chairman Orrin Hatch has said he will keep that separate from a tax overhaul. Republican leaders have said they won’t try again on the health-care law until fiscal 2019.

Balanced Budget

When Republicans attempted to use the 2017 budget process to repeal Obamacare earlier this year, they didn’t provide a 10-year plan for reducing the deficit.

The new Senate plan proposes a balanced budget within nine years, while leaving it to other committees to figure out how to achieve that. The proposal calls for $4.8 trillion in spending cuts over 10 years and $1.635 trillion in revenue losses, including the tax cuts. Balance by 2026 is achieved by assuming $1.2 trillion in economic growth, in part due to the tax cuts. Enzi claims to achieve a $197 billion surplus in 2027.

The Republican assumptions of robust economic benefits from the budget were called into question by a separate CBO analysis. CBO predicted that the budget would reduce economic growth in the first two years and slightly increase it in later years.

CBO estimated that annual real GDP growth in the first two years would average 1.3 percent, down from an average of 1.6 percent in CBO’s baseline. In later years, real GDP growth would be 2.0 percent, compared with 1.9 percent in the CBO baseline.

The budget, unlike the one proposed by Trump in May, would hold defense spending at the current budget cap instead of the president’s proposed $489 billion defense increase over 10 years. Non-defense discretionary appropriations — which fund domestic agencies like the Agriculture Department and National Institutes of Health — would be cut by $632 billion over 10 years compared with $1.6 trillion in Trump’s budget request.

While the Trump and House budget proposals contain a number of nonbinding policy suggestions to carry out their spending cuts, Senate Republicans — weary of policy infighting — are keeping things vague.

Medicare, Medicaid

The House budget seeks to make $203 billion in cuts in entitlements such as Medicare, Medicaid and food stamps, and it could be used to fast-track changes to the Dodd-Frank financial law. The Senate plan avoids those options.

The Senate proposal does allow adjustments to increase the defense spending caps. It also urges senators to revise the Children’s Health Insurance Program, improve management of wildfire-prevention funding, prevent private-pension bailouts and improve services to veterans.

The budget resolution doesn’t address Social Security, which will run a trillion-dollar-plus deficit in the coming 10 years. In the past, Republicans have sought to balance a “unified budget” that includes the program. This time, they are keeping it “off-budget.”

CBO says that without the Social Security accounting move, Enzi’s budget would never balance and would show a $424 billion deficit in 2027.

The nonpartisan Committee for a Responsible Federal Budget said in a statement it prefers the House budget. “We encourage the Senate to look to the House Budget Committee, which passed a budget calling for revenue-neutral tax reform and at least $200 billion of mandatory spending cuts on top of that,” it said.

Dynamic Scoring

The Senate plan renews authority for the CBO and Joint Committee on Taxation to use so-called dynamic scoring when evaluating bills — a move allowing lawmakers to assume that tax cuts will cause economic growth that would offset some of the revenue loss.

And it changes several rules to allow senators to rush a tax bill through, including abolishing the need for a CBO analysis at least 28 hours before a vote.

The Senate plan avoids other tricks, though. Enzi included provisions to keep appropriators from using phantom cuts known as “changes to mandatory programs” to offset discretionary spending increases.

The chairman also rejected pressure from some lawmakers to use a baseline number for tax revenue that would allow $450 billion in additional tax cuts. Instead, he stayed with the baseline used by the CBO.

Polling Spotlight: A silver lining for the GOP on Obamacare repeal

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There is good reason to question the assumption that by failing once again to pass legislation repealing and replacing the Affordable Care Act, Republicans have shot themselves in the foot. Although the CBO (Congressional Budget Office) could not analyze in its usual detail the consequences of Graham-Cassidy, it was able to determine that the legislation would cut federal funding for Medicaid by more than $1 trillion over the next decade, throwing millions of low-income Americans off the rolls.

This outcome would have generated a huge political problem for Republicans. A Public Religion Research Institute poll released Monday found 69 percent of Americans opposed to cuts in Medicaid, with only 28 percent in favor. The opposition included 78 percent of Democrats, 69 percent of Independents—and 55 percent of Republicans. In a related finding, nearly 45 percent of Americans are worried that they or a member of their family will lose health coverage in the coming year.

No doubt, failing to act on Obamacare will anger a portion of the Republican base, adding fuel to the insurrection against the Republican establishment and depressing turnout in states and districts where Republican incumbents who support the party’s leadership are running for reelection. But in the long run, it would have been more politically damaging to deprive low-income Americans, including millions of Trump supporters in red states, of the Medicaid coverage they would otherwise have enjoyed.

As behavioral economists have shown, the fear of loss is more acute than the hope of gain. Health policy perfectly illustrates this proposition. Whoever moves to change the status quo must convince people that they will not lose what they already have. The larger the share of people who are satisfied with the status quo, the tougher the task. This is why President Obama put his personal credibility on the line to assure Americans that if they liked their current insurance policy, they could keep it under his proposed reform. When this turned out not to be entirely true, he and his party suffered.

But now, after almost eight years of public disapproval, Obamacare has become the new status quo, the baseline from which most people assess gains and losses. While opposition to Obamacare still exists writ larger, individual provisions—some of which have been under threat from Republican alternatives—are wildly popular among Americans. By threatening to take Medicaid away from millions of people, the Republicans poked a hornets’ nest. Whatever they did after this, they would have been hurt. But by running away, they at least minimized the number of stings. Their legislative failure was a blessing, very effectively disguised.

Socialized Medicine Has Won the Health Care Debate

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“It’s coming down to a choice between Federalism vs Socialism,” Senator Lindsey Graham proclaimed on Twitter earlier this week. “I chose Federalism of #GrahamCassidy.” His tweet echoed his words at a press conference days earlier, where he framed his Affordable Care Act repeal bill as the only way “to stop a march toward socialism.”

It’s unclear if the Republican senator realized that he was cribbing from socialist revolutionary Rosa Luxemburg. In a pamphlet composed a century ago while in prison, Luxemburg wrote: “Bourgeois society stands at the crossroads, either transition to socialism or regression into barbarism.” Graham, presumably, didn’t mean to liken his bill to barbarism. But increasingly, those are the terms in which Americans view the health care debate—as a choice between socialism and regression. Republicans have used “socialized medicine” as a bogeyman—and they’ve steadily lost ground on the issue. Despite Graham’s attempts to portray the idea of caring for sick people regardless of their income level as a “nightmare” scenario, just 7 percent of those polled thought Graham-Cassidy would help them.

The repeated rebukes of attempts to undo Obamacare have shown that the average American is no longer moved by the threat of the “S-word.” If we are on a slippery slope toward socialized medicine, it appears that Americans are just fine with that. For the left, there’s a lot to learn from the successful battles against going backward on health care—lessons about how Trump-era politics can be used to push “socialist” policies that move Democrats, and the American public, forward in unexpected ways.

Introduced after the Bernie Sanders Medicare for all bill made its debut with 16 co-sponsors in the Senate, the Graham-Cassidy bill looked all the worse by comparison. Both bills arrived at the end of a summer of activism, a summer that has treated us repeatedly to the sight of people in wheelchairs carted out of the Senate chanting, “No cuts to Medicaid! Save our liberty!” The health care movement has been led by the people directly affected—people with disabilities, in many cases, along with veterans of the AIDS movement. They understood the power of spectacle, initiating those dramatic clashes at the Capitol. They also know better than anyone the inequalities baked into the existing system. Their fighting skills were honed fighting for decades against those who say, implicitly or explicitly, that they don’t deserve care.

Of course, politicians have long been disconnected from the American public on the issue of health care. But the movement to defend Obamacare has drawn into stark relief the difference between what people want and what politicians want to offer. Republicans like Graham banked on the attachment Americans have to the class system we like to pretend doesn’t exist. They played on the idea, honed through decades of dog-whistles, that government programs are always giveaways for the undeserving poor and people of color. As one law professor and conservative columnist complained on Twitter, “Years from now, when your child is denied a liver transplant bc of transplant diversity goals, you’ll be sorry you allowed single-payer.”

In the U.S., we tend to either deny the existence of class or treat it like a set of characteristics divorced from power relations. A Make America Great Again baseball cap, a taste for Budweiser and NASCAR—those, rather than income level or accumulated wealth, are the signifiers of class that we understand. Meritocracy is supposed to be the thing we have instead of class; you can hear it in the endless bipartisan odes to the ability to work hard and achieve anything—including, apparently, a liver transplant if necessary.

Barack Obama and Ben Carson are both heroes of the meritocratic tale, though with a different partisan inflection. Even Sanders falls victim to the meritocratic narrative at times, with his refrain that “No one who works 40 hours a week should be living in poverty.” The implication that comes with Sanders’s qualifier is that there are some people who may, in fact, deserve to be living in poverty. If class is just about some personal preferences rather than structures that maintain inequality, then it’s fine to maintain a healthcare system that treats only those who can afford it. After all, if they just worked harder, they’d have earned that liver.

Graham’s single most tone-deaf argument to sell his bill was drawing an analogy to welfare reform. Welfare reform, of course, was sold to the country by Reagan, Gingrich, and Bill Clinton through fearmongering about undeserving black mothersand “young bucks.” Graham’s rhetoric about the size of the Medicaid budget leaned hard on this analogy, hoping that Americans resented Medicaid as much as they were taught to resent welfare.

Like welfare reform, Graham-Cassidy would have turned Medicaid and the subsidies in the ACA into block grants for the states to manage as they see fit. But the problem with health insurance is that it is designed to be used. The goal of welfare reform was to kick people off of welfare; the goal of healthcare reform was theoretically to get more people onto health insurance plans. Welfare reform increased poverty; Graham and Cassidy didn’t want to admit their bill would do the same. The analogy failed, though it told us a lot about what Republicans think of the people who use Medicaid.

The ham-handed Republican attempts to dismantle the health care system—the “socialism” warnings, the appeals to the selfishness of privileged white folks—have only reinforced the public’s support for government taking care of its citizens. It was telling how, in Monday night’s televised debate between Graham and Cassidy and Senators Sanders and Amy Klobuchar, Graham fell right into a trap, unintentionally proving his opponents’ point about what Americans want. When Sanders asked, “Do you know what the most popular health insurance program in America is? It’s not the private insurance industry,” Graham jumped in like an overeager schoolchild: “It’s Medicare,” he said.

Both Republicans and Democrats have badly misunderstood what makes Obamacare unpopular. What people don’t like are the inequities that still prevail in our health care system, not the fact that “government is too involved.” When Vox’s Sarah Kliff visited Whitley County, Kentucky, to talk to Trump voters who benefited from the ACA, she heard complaints from those buying private insurance with their subsidies that their deductibles were still too high for them to access care. Others, not surprisingly, were angry that the very poor got Medicaid, while they had to pay monthly premiums for care they rarely used. But that anger hasn’t turned them against the program. Medicaid expansion—the “socialized” part of the ACA—remains wildly popular, with 84 percent of those polled by Kaiser Family Foundation saying it’s important to keep the expansion.

The ACA’s means-testing sets up a hierarchy of plans that at times seem calculated to fuel resentment of those getting “free stuff.” It also requires hours of work—I write from personal experience, as a freelancer who has attempted to explain repeatedly that my income varies from month to month and year to year—to prove to the system that you are not getting away with something you haven’t qualified for.

The ways that people have tried to patch the gaps that remain in Obamacare, through charities and crowdfunding, have also highlighted its inequities. As Helaine Olen recently wrote in The Atlantic, charities, too, are often means-testing applicants, while crowdfunding introduces a new kind of means-testing—“means-testing for empathy,” as writer Patrick Blanchfield told me recently. Most GoFundMe or YouCaring campaigns for medical bills don’t go viral; only around 10 percent of them met their stated goals. For those who have a big social media audience, or whose particularly compelling story takes off, crowdfunding might work. But the glut of such campaigns leaves people weighing story against story, deciding who is going to get their donations. It’s health care by popularity contest.

By focusing on the not-good poll numbers for Obamacare, politicians and pundits have missed the whole point: The law didn’t go too far for Americans to get behind. It didn’t go far enough. And while single-payer opponents continue to evoke rationed carelong lines and wait times, and other problems that supposedly plague England or Canada, the public seems well aware that the reality for many Americans is far worse. By their very complaints, the pundits and politicians continually highlight the inequality in the system; the complainers are those who can afford the kind of carethat comes with personal attention, privacy, shorter waits, and avoidance of rubbing elbows with undesirables.

To move forward, then, the single-payer movement should double down on what we learned through this fight: that expanding Medicaid made it harder, not easier, to claim that the program is a “giveaway” to undeserving poor. The willingness of people with disabilities to claim and hold the spotlight—as the New Republic’s Sarah Jones has written—has helped to challenge our preconceptions about who relies on Medicaid ,and to make politicians confront those who will not be served by a market-based program. And the willingness, finally, of politicians to fight publicly for single-payer—rather than mournfully shake their heads and say it will never happen—expands the range of policies that even establishment media is willing to discuss.

Most important, we have learned that the old fearmongering tropes about socialism are no longer enough to whip Republican votes for a major plank of their own platform. If anything, the successful fight should help progressives shed their fears of boldly advocating for what they know is right and working to change public sentiment without endlessly obsessing over potential political pitfalls.

It seems that barbarism, to Graham and his ilk, is the idea that they would lose their right to segregated, high-end care to some undeserving, poor person of color. To the rest of us, however, barbarism is a system that decides who deserves to live or die by the color of their skin, the money in their bank account, the hours that they work, or their ability to work at all. This is now an American consensus. And if socialism is the medicine our system needs, the country is ready to embrace it—even by name.

Obamacare Repeal Bills, Like ‘Game of Thrones’ White Walkers, Are Very Difficult to Kill

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Michele and Igor speak with Andy Slavitt, former acting administrator at the Centers for Medicare and Medicaid Services under former President Barack Obama—and Twitter hero—about the latest efforts in Congress to repeal the Affordable Care Act in the form of the Graham-Cassidy bill. He reminds listeners why health care is far more personal and significant than partisan politics and how to work toward universal coverage.


3 Ways the Senate Budget Reopens the Door for ACA Repeal

After the latest failed attempt to repeal the Affordable Care Act (ACA) in the Senate, Sens. Lindsay Graham (R-SC) and Ron Johnson (R-WI) declared that they would only support a new budget resolution that enabled them to keep trying to force through their own health care bill. The Senate has not had to meet the 60-vote standard to pass ACA repeal because of the budget reconciliation process, which lets the Senate pass legislation with a simple majority vote. This process began with reconciliation instructions included in the fiscal year 2017 budget that Congress passed in January 2017, but those instructions expire on September 30.

While the new FY 2018 budget resolution from the Senate Budget Committee retreats from ACA repeal to some extent—after massive public opposition—it would still enable Congress to revive major elements of ACA repeal using reconciliation. Here are three ways the proposed Senate budget supports ACA repeal.

1. An overly broad reconciliation instruction to the Senate Finance Committee

The Senate Finance Committee has jurisdiction over both tax policy and several federal health care programs, including Medicare and Medicaid. If the Senate wanted to limit the scope of a reconciliation bill to tax policy, the budget resolution could give instructions to the Senate Finance Committee that only cover revenues. Instead, the budget instructs the Finance Committee to produce legislation that increases deficits by up to $1.5 trillion over 10 years.

Since deficit changes can be accomplished via changes to both spending and revenues, the Finance Committee could use this reconciliation instruction to repeal ACA-related taxes as well as much of the spending that helps people purchase health insurance under current law. Politico reports that “95 percent of health care policy” goes through the Senate Finance Committee, according to a Republican Congressional staffer discussing ACA repeal. As a result, the staffer said, “it’s not like we couldn’t slip it in anyway.”

Every dollar the Finance Committee cuts from health care could be used to pay for tax cuts for the rich that would be on top of the $1.5 trillion tax cut financed by deficits. This reconciliation instruction could let Congress pass a huge deficit-financed tax cut for the wealthy and corporations, combined with major elements of ACA repeal, in a single omnibus reconciliation bill. If the Finance Committee’s overall bill does not increase deficits by more than $1.5 trillion over 10 years, the Senate could pass it on a party-line vote under reconciliation.

Aside from the Finance Committee, the only other committee involved in ACA repeal in the Senate is the Health, Education, Labor, and Pensions (HELP) Committee. The Senate budget resolution does not give a reconciliation instruction to the HELP Committee, which signals a meaningful retreat from full ACA repeal. Nevertheless, the Finance Committee instruction would still enable the Senate to change major parts of the law, which could include nullifying the ACA mandate for individuals to purchase health insurance, repealing the ACA-related taxes that finance the coverage expansion, and making all of the Medicaid cuts in earlier ACA repeal legislation, such as repealing the Medicaid expansion and making further cuts by turning the program into a block grant.

2. A deficit-neutral reserve fund for ACA repeal

The Senate budget resolution further smooths the path for ACA repeal with a deficit-neutral reserve fund for “repealing or replacing” the ACA. This allows Senate Budget Committee Chairman Mike Enzi (R-WY) to adjust the aggregates that are included in the budget resolution, such as overall spending and revenue levels, to accommodate ACA repeal. This reserve fund helps the Senate majority avoid points of order that could otherwise create hurdles for passing a future health care bill. A similar reserve fund was also included in the FY 2017 budget resolution.

Budget resolutions often include many reserve funds that are mostly designed to signal rhetorical support for an issue. Not only does the reserve fund for health legislation smooth the way for ACA repeal, it also shows that supporters of the Senate budget continue to endorse ACA repeal even after the FY 2017 reconciliation instructions expire on September 30.

3. Deficit-financed tax cuts

Even if Congress does not go after the ACA using reconciliation instructions in the FY 2018 budget, the deficits from the tax cuts the Senate budget enables will be used by the ACA’s opponents to attack the law in the future. Whipping up hysteria about budget deficits is a common tactic to advocate cuts to programs such as Medicare and Medicaid, and it is already being used to justify ACA repeal. When asked a question on CNN from a person who had recovered from substance abuse addiction and who worried about loss of Medicaid coverage for treatment for others suffering from addiction, Sen. Graham responded, “Let’s talk about $20 trillion of debt.”

If lawmakers increase the debt with the very tax cuts that Treasury Secretary Steven Mnuchin says will be “done by the end of the year,” it will add further fuel to their drive to slash programs for low- and middle-income Americans using reconciliation instructions in their next budget resolution for FY 2019. This will not be a long delay—the FY 2019 budget would be passed by April 15, 2018, if Congress follows the schedule for the regular budget process.

Lawmakers can cut taxes, increase deficits, and use those higher deficits to justify a renewed push to repeal the ACA, all before the 2018 midterm elections.


The window is closing for Congress to pass ACA repeal using the FY 2017 reconciliation instructions, but the Senate Budget Committee is reopening it with the FY 2018 budget. The quest to repeal the ACA—thereby cutting taxes for the wealthy, taking health insurance from tens of millions of Americans, eliminating protections for preexisting conditions, and driving up out-of-pocket costs—will continue if Congress passes the Senate budget resolution.