Congress at crossroads after another GOP health care failure

http://abcnews.go.com/Health/wireStory/congress-crossroads-gop-health-care-failure-50121420

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Congress is at a crossroads after Republicans’ stinging failure to repeal Barack Obama’s health care law. But what’s next — more partisan conflict or a pragmatic shift toward cooperation?

Unless Republicans and Democrats in Congress can work together, and bring along an often unpredictable President Donald Trump, political conflict over health care may spread. Bipartisan talks on legislation to stabilize shaky insurance markets are on again, but time is short and there’s no guarantee of success.

Congress also has yet to renew funding for programs that traditionally enjoy broad support, such as children’s health insurance and community health centers, despite approaching deadlines.

Feelings were raw Tuesday after Senate GOP leaders announced they would not take their latest “repeal and replace” bill to the floor for lack of support. Some lawmakers said it’s still possible to bridge the partisan gap on a limited set of priority issues.

Sen. Lamar Alexander, R-Tenn., said he would resume efforts to reach a bipartisan deal with Sen. Patty Murray, D-Wash., to stabilize markets for individual insurance policies that 18 million people rely on. More than half of those consumers are covered under the health law.

Alexander is chairman of the Senate Health, Education, Labor and Pensions Committee; Murray is the top Democrat on the committee. Alexander runs the risk of being accused by some fellow Republicans of trying to “bail out Obamacare.”

Murray is under pressure from fellow Democrats not to make concessions to Alexander, who is seeking changes that would make it easier for states to get waivers from some of the law’s requirements, potentially leading to plans with lower premiums.

“I’m still concerned about the next two years, and Congress has an opportunity to slow down premium increases in 2018, begin to lower them in 2019, and do our best to make sure there are no counties where people have zero options to buy health insurance,” Alexander said in a statement.

Sen. Ron Wyden, D-Ore., who has worked with Republicans on a range of health care issues, said cooperation is the only way to avoid creating needless problems for constituents.

“You recognize the opportunities that are in front of you,” said Wyden, the top Democrat on the Senate Finance Committee, which oversees health care funding. “My hope is we can come together.”

Wyden’s list includes renewing the Children’s Health Insurance Program for 9 million kids, whose funding expires this week, as well as short-term action to stabilize the Affordable Care Act’s insurance markets, by guaranteeing subsidies for copayments and deductibles. Experts say that could cut expected double-digit premium increases in many states by about half.

The missing ingredient seems to be leadership, say outside observers.

Neither Trump, nor House Speaker Paul Ryan nor Senate Majority Leader Mitch Connell has given clear approval for a bipartisan approach. Some governors have called for a health care reset that would involve both parties working together on a limited agenda, but their suggestion hasn’t been embraced in Washington.

“The question is whether you can you forge a coalition that doesn’t include either the hard right or the hard left,” said GOP health economist Gail Wilensky. “I have not been able to answer who would provide the leadership for such an effort. Neither the leadership in the House or the Senate has embraced the notion of trying to forge a bipartisan coalition, and it is very hard to move legislation without that.”

Rep. Richard Neal, D-Mass., said Trump at a meeting with lawmakers raised the possibility of seeking a deal with Democrats. There’s no hint what that might entail.

If anything, Democrats have been moving to the left after Sen. Bernie Sanders, I-Vt., relaunched his “Medicare for all” plan recently. Under Sanders’ plan, government would pay for medical services, replacing employers and insurers. Some liberal activists argue that support for “single-payer” should be a qualifying test for Democratic candidates in 2018 and beyond.

Other Democrats say single-payer would lead to political defeat, because of the massive tax increases required.

“It’s not going to happen,” said former Rep. Henry Waxman, D-Calif., one of the main authors of the Obama law. “You can talk about it, and plant a flag, and say that’s where you’d like to go, but in the meantime people need their insurance coverage.”

Wednesday is the deadline for insurers to sign contracts to offer policies for 2018 on the health law’s markets. Sign-up season starts Nov. 1. About half the 18 million Americans with individual policies get no subsidies under the health law. Without congressional action some are facing premiums that rival a mortgage payment.

Saturday is the deadline for Congress to act on children’s health insurance and community health center funding. Brief delays are not expected to cause disruptions, but a protracted holdup would.

 

What Republicans must answer about their next steps on health care

https://www.brookings.edu/blog/fixgov/2017/09/26/what-republicans-must-answer-about-their-next-steps-on-health-care/?utm_campaign=Governance%20Studies&utm_source=hs_email&utm_medium=email&utm_content=56772969

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Congressional Republicans’ last-ditch efforts at repealing the Affordable Care Act using the budget reconciliation process appear to have failed. The procedural protections that prevent a filibuster of the current bill expire on September 30, when the government’s new fiscal year begins. But is the option of party-line legislating on health care really off the table for good? It depends, in large part, on Republicans’ answers to the following three questions:

1. Can Republicans agree to a new budget resolution?

To use the fast-track reconciliation process in a given fiscal year, Congress must first adopt a budget resolution that contains reconciliation instructions, or language outlining which congressional committees will develop reconciliation legislation. When the 115th Congress began in January, the plan was to use the process twice: once for health care (with instructions initiated by the fiscal year 2017 budget resolution) and then a second time for tax legislation (with instructions contained in the fiscal year 2018 budget resolution).

With the FY2017 health care attempt now exhausted, Republicans could write FY2018 instructions that allow them to tackle both policy goals. On one hand, this would not be that difficult. Two committees that have substantial jurisdiction over health legislation—House Ways and Means and Senate Finance—also are responsible for taxes, so will already be included. Other health-related committees (House Energy and Commerce and Senate Health, Education, Labor and Pensions) could be given relatively small deficit reduction instructions to cover all necessary bases.

On the other hand, however, Republicans have struggled to come to agreement on what a budget resolution with reconciliation instructions for 2018 would look like—and that’s without introducing health care into the fight. One of the challenges in reaching agreement on a 2018 budget has been House conservatives’ insistence that they need more details on a tax bill before they support the budget resolution that will initiate said legislation. Senator Lindsey Graham (R-S.C.) threatened over the weekend that he “will not vote for a budget resolution that doesn’t allow the healthcare debate to continue.” While it would be relatively easy to meet that demand in principle, might other Republicans insist on more details or other promises related to health care in exchange for their support of the budget resolution? In the Senate especially, the GOP can spare relatively few votes and still adopt the resolution needed to kick off the reconciliation process.

2. Should health care and taxes be tackled separately or together?

Under current interpretations of the reconciliation procedures in the Senate, there are limits on the number of reconciliation bills Congress can consider each fiscal year. Reconciliation measures may make three kinds of budgetary changes: changes in revenue, changes in spending, and changes to the debt limit. If one bill contains more than one kind of change, that counts as the Senate’s attempt at both categories.

This year’s attempts at rolling back the Affordable Care Act have included both spending and revenue provisions. If Republicans want to pass health care changes that follow the same general outline from earlier this year—that is, eliminate the ACA’s taxes and pay for it with cuts on the spending side—they would have two choices. One, they could put all the spending AND revenue provisions from both their health care AND tax proposals together in one bill. Or, they could cleave the spending-side provisions off into a separate piece of legislation from the revenue items and attempt two different bills. The last two times Congress used the reconciliation process to make major changes in spending and taxes in the same year—1997 and 2005—it was by using this two separate measures approach.

The first option has a number of challenges (see #3 below), but so does the second. First, there are some aspects of the ACA that touch both revenue and spending, which could make it difficult to actually separate the two halves. Second, only about a quarter of currently serving House Republicans and roughly half of currently serving Senate Republicans were in Congress the last time their party attempted such a move, so many members lack experience with the process. A health care spending-only bill would still have to meet the various requirements of the reconciliation process, including those imposed by the Byrd Rule, and much of the Republicans’ intra-party disagreement so far has been over the spending-side substance of the measure. Republicans would also have to choose which bill to tackle first: the health care measure that has been front and center all year, or the tax legislation widely believed to just as important to key parts of the Republican base. If whatever they choose first takes up significant time, the calendar might prevent action on the second—especially in an election year.

3. If the answer is “together,” how do Republicans get to “yes”?

Suppose Republicans decide they are willing to try to tackle health care and taxes in the same, filibuster-proof legislation—and can adopt a budget resolution that allows them to do so. So far, writing a health care bill with majority support in the House and Senate has proved elusive. The path to tax legislation hasn’t been much smoother. And while there are some situations where logrolling across multiple hard issues actually generates a bill that’s easier to pass; a former Representative Barney Frank (D-Mass.) once said, “the key to understanding deal making Congress is to remember that the ankle bone is connected to the shoulder bone. Anything can be the basis of a deal.” But this year has presented little evidence to suggest that putting tax legislation and health care together in one measure would be one of those situations. Given how much time and energy Republicans have spent thus far with nothing to show for it on health care, many may be reluctant to tie the fate of a tax bill to an issue where victory has been so difficult.

The fate of the Affordable Care Act specifically does not, of course, rest just with Republicans’ immediate choices about reconciliation legislation in fiscal year 2018. The Department of Health and Human Services, for example, is taking actions that many see as undermining the implementation of the law—decisions the Department can make and pursue without any congressional action whatsoever. But on the legislative front, while party-line legislating to rollback Obamacare remains possible, the political path to success is likely to get harder, not easier, in the short term.

Senate won’t vote on ObamaCare repeal bill

Senate won’t vote on ObamaCare repeal bill

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Senate Republicans have decided to not vote on their latest ObamaCare repeal legislation, signaling a collapse in their last-ditch effort to kill off President Obama’s signature law.

“It would appear not,” Sen. Pat Roberts (R-Kan.) told reporters when asked about the prospect of a vote this week.

Senate aides confirmed the decision.

The legislation sponsored by Sens. Bill Cassidy (R-La.) and Lindsey Graham (R-S.C.) would dismantle ObamaCare’s insurance subsidy program and Medicaid expansion and convert their funding into block grants to states.

Senate Republicans said Tuesday that they will continue to work on health-care reform, even though they will likely miss the Sept. 30 deadline for the special reconciliation bill that would allow them pass legislation with a simple majority vote.

Senate Majority Whip John Cornyn (R-Texas) said earlier in the day that the Graham-Cassidy proposal to turn ObamaCare into state block grants was “a good idea” but said that lawmakers need more time to “socialize” it through public advocacy.

Sen. Susan Collins (Maine), one of three Republicans to publicly say they opposed the measure, urged colleagues to resume bipartisan negotiations in the Senate Health Committee between Chairman Lamar Alexander (R-Tenn.) and Sen. Patty Murray (D-Wash.).

“I think the best route is for us to resume the hearings in the HELP [Health, Education, Labor and Pensions] Committee that we were doing before we were diverted by Graham-Cassidy,” Collins told reporters.

She said “it would be helpful if the vice president outlined his support for resuming the hearings in the HELP Committee and the negotiations that were making such good progress,” she said ahead of a Republican lunch with Vice President Mike Pence.

Sen. James Lankford (R-Okla.) said Senate Republicans should “continue to negotiate until we get it solved.”

But Lankford does not want the health-care debate combined with the upcoming tax-reform debate.

Instead, he said that colleagues should continue to negotiate behind the scenes on replacing ObamaCare while a projected $1.5 trillion tax package takes center stage.

“We need to keep the two separate but both have to keep going,” he said. “You can’t not do health-care issues when everybody around the country are facing double-digit [premium] increases and hospitals are merging,” he said.

“Keep working behind the scenes until we get it resolved and ready for the floor.”

There had been talk about including ObamaCare repeal in a new budget reconciliation measure that has been planned for tax reform. That would allow both ObamaCare repeal and tax reform to be brought up under special rues that would prevent a filibuster.

But that would also put tax reform at risk by pairing the issue with health care, and a number of key Republicans, including Cornyn and House Freedom Caucus Chairman Mark Meadows (R-N.C.), voiced opposition to that plan on Tuesday.

Graham, Cassidy don’t want a vote on their health care bill

https://www.axios.com/there-wont-be-a-vote-on-graham-cassidy-health-care-bill-2489852728.html

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The Senate seems unlikely to vote on its latest bill to repeal parts of the Affordable Care Act, two senior GOP aides said. At the GOP caucus lunches this afternoon, the bill’s sponsors — Sens. Bill Cassidy and Lindsey Graham — asked not to hold a vote, after it became apparent the bill wouldn’t pass. Leadership wants them to announce that decision, aides said.

What happens next: Expect much more discussion about whether to include both health care and tax reform in the 2018 budget, which would let Republicans make another attempt at passing a bill on a party-line vote.

Presidential candidates in fantasy land over health care

https://www.publicintegrity.org/2015/09/28/18071/presidential-candidates-fantasy-land-over-health-care

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Commentary: candidates say this and that about health care, but it’s the insurers and pharmaceutical companies that call the tune.

Presidential candidates from both parties are full of sound and fury about various aspects of the U.S. health care system, but unless we as a nation get serious about big money in politics, all the noise will ultimately amount to nothing.

Every one of the Republican candidates has pledged to repeal and replace the Affordable Care Act. But I’m not sure they realize that the interests of the insurance and pharmaceutical industries,  as well as hospitals and physicians,  were considered first and foremost as the law was being drafted.

Yes, Obamacare has brought some needed reforms to the insurance marketplace and has enabled millions of previously uninsured Americans to finally get coverage. But health insurers have not only thrived since the law was passed, they are more profitable than ever, and that has made their executives and investors happy—and richer. The stock prices of the five largest for-profit insurers have tripled and in some cases quadrupled since the law was passed.

And now that many more people can afford to see a doctor and pick up their prescriptions and hospitals are not having to provide as much charity care, most health care providers would be just as upset as the insurers if a repeal of the law became a real possibility.

On the Democratic side, Hillary Clinton and Bernie Sanders have both announced plans to fix some of the problems not addressed by the ACA.  Both of them said they favored allowing Medicare to negotiate with pharmaceutical companies for lower prices and they both want to make it legal for Americans to re-import drugs from Canada and elsewhere.  They also criticized the outsized profits of many drug makers and pledged to force the companies to provide more information about how much they actually spend on research and development.

Clinton also proposed capping out-of-pocket drug spending for some people with chronic conditions at $250 a month. Even though her campaign acknowledged that the cap would apply to only about a million people, the proposal drew sharp rebukes from both the insurance and pharmaceutical industries.

America’s Health Insurance Plans, the industry’s largest PR and lobbying group, said it opposed any plan “that would impose arbitrary caps on insurance coverage.”

AHIP even criticized Clinton’s and Sanders’ plans to enable Medicare to negotiate for lower drug prices, saying that imposing caps and “forc(ing) government negotiation on prescription drug prices will only add to the cost pressures facing individuals and families across the country.”

If you’re wondering why insurers don’t want Medicare to have the ability to negotiate with drug companies, here’s why: it would make their Medicare Advantage plans, which offered prescription drug benefits to seniors long before the traditional Medicare program could, much less attractive. The irony is that private insurers can negotiate with drug companies but the federal government cannot.

And if you’re wondering why that is, here’s why: lobbyists for drug companies and insurers have defeated every bill that has been proposed over the years to allow Medicare to negotiate for drug prices, just as they have been able to defeat every bill—even those with bipartisan support—that would allow Americans to order medications from Canadian pharmacies.

When Congress was considering legislation to add a prescription drug benefit to Medicare in 2003, industry lobbyists insisted that language that would have authorized the government to negotiate with drug companies be stripped out of the bill.  Six years later, they won again when they the Obama administration caved in to pressure from the drug companies and made certain that the ACA would not include drug negotiation authority for Medicare. This despite the fact that Obama had said when he was a senator from Illinois that, “Drug negotiation is the smart thing to do and the right thing to do.”

In fact, the drug companies always win, which is why Americans pay far more than citizens of any other country for prescription medications. We pay exactly 100 percent more per capita for pharmaceuticals than the average paid by citizens of the 33 other developed countries that comprise the Organization for Economic Cooperation and Development (OECD).

Obama also once supported drug re-importation, as did Sen. John McCain, the Arizona Republican who lost to Obama in the 2008 presidential election. In 2012, two years after the passage of the Affordable Care Act, McCain teamed up with Sen. Sherrod Brown, (D-Ohio) in another attempt to get Congress to pass a drug re-importation bill.

When it became clear that his bill would not pass, McCain took to the floor to denounce the ability of well-financed special interests to control the federal government.

“What you’re about to see is the reason for the cynicism that the American people have about the way we do business in Washington. (The pharmaceutical industry)… will exert its influence again at the expense of low-income Americans who will again have to choose between medication and eating.”

Don’t expect that to change anytime soon. As long as interest groups can spend unlimited amounts of money to influence elections and can hire hundreds of lobbyists to do their bidding, millions of Americans will have to decide between health care and eating, while executives and shareholders get richer and richer.

Little-known ACA provision could have big impact on hospitals’ bottom lines

http://www.fiercehealthcare.com/finance/finance-affordable-care-act-hospital-reimbursement-medicare?utm_medium=nl&utm_source=internal&mrkid=959610&mkt_tok=eyJpIjoiWmpSaVpqZGxPREF5TlRBMiIsInQiOiJCamZSYmt6YkZzc0FcL2J1NWFyaFBTRHdtT2Rwd3BKbnI0OGQ5RW1jWXhEcklUa2RYcjVOU2JhWEJXTFBuRlJEcnJRWXVXd0ROT0drZmF5WG00dkVYNFY2QmtMWk1BTUFXRmVtcmUwWVhHdnNKejA2dlZBMmhYbGVyVW9EazZtZTUifQ%3D%3D

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Investors should keep a close eye on healthcare, as a little-known element of the Affordable Care Act could leave some hospitals strapped for cash.

The ACA allows Medicare to adjust reimbursements based on workers’ productivity, meaning reimbursement rates decrease as productivity grows in the economy, according to an article from The Wall Street Journal.

The Congressional Budget Office projected (PDF) that this piece of the law would cause reimbursement rates to grow at 2.2% each year between 2012 and 2025, a decrease from 3% growth.

These changes could hurt the bottom line for hospitals. Although the consumer-price index for medical care has been slowing, it has grown by an average of 2.9% over the past five years, according to WSJ. A lengthy window of costs rising faster than reimbursement would widen the gap between revenue and cost.

In general, Medicare already pays less in reimbursement than commercial insurers. The CBO report suggests that if the reimbursement changes stick, the number of hospitals unable to turn a profit could reach 60% by 2025.

WSJ’s analysis did note, however, that this grim outlook did not take into account increased cost efficiency at hospitals. It also noted that the political climate, as the GOP continues to push for a repeal of the ACA, leaves plenty up in the air.

“The good news for investors is that most hospitals aren’t for-profit and few have publicly traded shares,” according to the article. “But the impact of financial pressure still could be significant.”

Also worth considering is the impact that the industry’s ongoing consolidation can have; Tenet Healthcare, for instance, is looking to divest its hospital portfolio.

The amended version of Graham-Cassidy is a mess

The amended version of Graham-Cassidy is a mess

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The revised bill was leaked last night and will apparently be unveiled today. The reporting has suggested that it’s worse than before. Not only is Graham-Cassidy now full of bribes and giveaways to lure hesitant senators, but it also makes it much easier for states to avoid the application of the ACA’s insurance regulations.

That’s because states that want to get out from under the ACA no longer have to submit waivers that the Trump administration has to then approve. They just have to submit applications. Once they do, section 204 of the bill appears to allow the states to establish their own rules for their insurance markets.

Section 204 is really convoluted. Even for lawyers who do this kind of thing for a living, it’s difficult to parse. And on one critical point in particular—whether insurers will be allowed to charge sicker people more for their coverage—it appears to be internally inconsistent.

In general, section 204 says that the states are free to adopt new rules for any insurance plans supported by the Graham-Cassidy block grants. To the extent that the states’ new rules diverge from certain specified ACA rules—the “non-applicable provisions”—the new rules supersede the ACA’s rules.

Which ACA rules can be superseded? It’s a familiar list: the requirement to cover the essential health benefits, the cap on cost-sharing limitations, and the obligation to sell tiered plans (gold, silver, bronze). Insurers can exclude preventive services, including contraception, and states no longer have to treat insurers as part of a single risk pool.

Look carefully at section 204(b)(2), however. It says that the rules that can be superseded include subsections (ii) and (iii) of 42 U.S.C. 300gg(a)(1)(A), which governs community rating. If you chase down that cross-reference, you’ll see that (ii) and (iii) allow health insurers to vary their premiums based on age and rating areas.

But here’s the key: the basic obligation of 300gg(a)(1)(A)—the requirement that premiums can’t vary along anything but the specified conditions—isn’t listed as one of the provisions that states can supersede. No matter what rules the states adopt, then, insurers still can’t discriminate based on health status.

Or can they? If you keep reading, section 204(c) asks states to supply a “description” of the state’s new rules. In that description, the state must specify “[t]he criteria by which, and the degree to which, a health insurance issuer of such coverage may vary premium rates for such coverage, except that in no case may an issuer vary premium rates on the basis of sex or on the basis of genetic information.”

The suggestion is pretty clear: states can allow insurers to vary their premiums, including on the basis of health status, so long as insurers don’t discriminate on the basis of sex or genetics. Plus, it doesn’t make much sense to give the states the freedom to establish separate risk pools if insurers still had to charge the same rate to everyone, healthy or sick.

So what the hell does section 204 mean? Can states discriminate on the basis of health status or not? Who knows?

The craziest thing is that the sloppy drafting may be intentional. It reads to me like a deliberate effort to allow senators to read whatever they want to into the bill. Senator Cassidy and other moderates can claim it preserves the protections for preexisting conditions. Senator Cruz and other conservatives can claim it doesn’t.

Both have a point—but they can’t both be right. One of them is being sold a bill of goods.

My own tentative view is that the statute doesn’t allow insurers to vary their rates based on health status. Nothing in section 204(c) expands the carefully specified list of ACA provisions that can be superseded. There’s internal tension, to be sure, but absent something more, my working assumption is that insurance plans nationwide will remain subject to rules on community rating.

Even if that’s right, however, Graham-Cassidy would still allow insurers to discriminate against the sick. States could liberate insurers to sell plans with huge deductibles and missing benefits, which will discourage sick people from signing up. Since those plans would be in their own risk pools, they could keep their premiums low. Sick people would then be forced into comprehensive plans with sky-high premiums. (Thanks to Tim Jost for walking me through this.)

However you read Graham-Cassidy, then, it allows insurers to screw sick people. It’s just not clear exactly how they can screw them.

GOP’s Obamacare Repeal Looks to Be on the Verge of Collapse … Again

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With just five days left for Republicans to pass an Obamacare repeal bill in 2017 without fear of facing a Democratic filibuster, the push by Sens. Bill Cassidy (R-LA) and Lindsey Graham (R-SC) entered a new phase Sunday night. Call it the “if at first you don’t succeed, try to buy the votes you need” stage. But even with the changes, the GOP’s health care reform effort looks likely to fall short.

What It Does: The revised legislation, formally introduced Monday, sweetens the deal for some states that just so happen to be home to senators who represent the deciding votes on the bill. The updated bill would still pool together Obamacare money for insurance subsidies and expanded Medicaid and deliver it to states in the form of block grants, but it changes the distribution of that funding. The bill also creates a carve-out allowing Alaska to get a 25 percent increase in federal Medicaid matching funds. And it makes it easier for states to roll back federal insurance regulations, a step that health care analyst Larry Levitt of the Kaiser Family Foundation says could leave people with pre-existing conditions priced out of insurance markets.

state-by-state summary of the effects of the bill released by Cassidy shows Alaska gaining 3 percent from 2020 through 2026 compared to current law, Arizona getting 14 percent more, Kentucky getting 4 percent more and Maine gaining 43 percent. Some analysts charge that the updated numbers aren’t accurate because they don’t reflect Medicaid spending caps introduced by the legislation while treating reduced spending by states as a result of the elimination of Medicaid expansion as “savings.”

What It Means: “The substance of the Senate’s latest health care bill is different from its predecessor, but the politics are not, in part because only a few Republican senators care about the substance of the bill,” Axios’s Sam Baker writes.

Sen. Rand Paul (R-KY) on Monday reiterated his opposition to the bill. Sen. John McCain (R-AZ) had objected to the bill on more fundamental grounds, saying last week that health care reform ought to go through a bipartisan process and regular order in the Senate. The current scramble hardly qualifies on either front. Sen. Susan Collins (R-ME) said Sunday that “it’s very difficult for me to envision a scenario where I would end up voting for this bill.” The revisions don’t do much if anything to address her stated concerns. And Sen. Ted Cruz has also voiced concerns about the bill. “Right now, they don’t have my vote and I don’t think they have Mike Lee’s vote either,” he said Sunday, referring to Utah’s junior senator. The changes haven’t gotten him to “yes.”

The Bottom Line: Even President Trump is skeptical about the bill’s chances of passing. “Looks like Susan Collins and some others who will vote against,” Trump said Monday during an interview with the Alabama-based “Rick & Bubba” radio show. “We’re going to lose two or three votes and that’s the end of that.”

One Other Complication: Even if this bill fails, the push to repeal Obamacare may not be over. Graham said Sunday that he and Sen. Ron Johnson (R-WI) would not vote for a 2018 budget resolution “that doesn’t allow the health care debate to continue.” Squeezing both health care and tax reform into the budget resolution may be possible, but it would further complicate an already difficult task for Republicans.

Five things to watch for in CNN’s ObamaCare repeal debate

Five things to watch for in CNN’s ObamaCare repeal debate

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CNN will host a health care debate Monday night between Senators as the GOP makes a last-ditch effort to repeal ObamaCare.

The debate pits GOP Sens. Lindsey Graham (S.C.) and Bill Cassidy (La.) against Sens. Bernie Sanders (I-Vt.) and Amy Klobuchar (D-Minn.) in a town hall-style event.

The debate will be moderated by CNN anchor Jake Tapper and chief political correspondent Dana Bash live from Washington, D.C.

Graham and Cassidy are the authors of the latest Republican ObamaCare repeal effort, which appears to be on life support given GOP defections from the right and center.

Sanders brings political star power to the debate, as well as some risk for Democrats. He is championing a single-payer bill that would revolutionize the nation’s health-care system, something Graham has lambasted as socialism. Republicans are expected to try to attack the Sanders proposal during the debate.

Here are five things to watch for.

Will Republicans turn Monday into a debate on single-payer?

If ObamaCare is not repealed, Graham says the U.S. will head toward a single-payer system.

“It’s coming down to a choice between Federalism vs. Socialism,” Graham tweeted Monday morning. “I chose federalism.”

Graham will likely put a big focus on Sanders’s “Medicare for all” bill, which he recently introduced with the support of 16 of his Democratic colleagues — though not Klobuchar.

Sanders is more likely to defend the Affordable Care Act than seek to tout his own bill.

“The focus is going to be on exposing Graham-Cassidy as the most destructive piece of legislation in the modern history of our country,” a Sanders aide told The Hill.

He will be “defending the ACA, as he has for the last nine months.”

Debating pre-existing conditions and Jimmy Kimmel

Sanders and Klobuchar are expected to zero in on Democratic arguments that the GOP bill would hurt people with pre-existing conditions.

While the bill would leave intact an ObamaCare rule banning insurers from denying coverage to people based on their medical history, Graham-Cassidy lets states waive requirements barring insurers from charging higher premiums to people with pre-existing conditions.

States may also waive out of essential health benefit requirements, which mandate what services insurers must cover.

The bill does require states to show how they will maintain access to “adequate and affordable health insurance coverage for people with pre-existing conditions,” but what that means is open for interpretation by the administration.

“Insurers might have to sell coverage to people with preexisting conditions, but it could be very expensive,” Tim Jost, a emeritus professor at the Washington and Lee University School of Law who opposes the bill, wrote in a blog Monday morning.

Democrats have an ally in the late-night comedian Jimmy Kimmel, who has advocated against several GOP repeal bills, including Graham-Cassidy.

Kimmel, whose son was born with a serious heart condition, last week accused Cassidy of lying to his face over the bill’s treatment of people with pre-existing conditions.

Cassidy had said the bill meets what he had called the “Jimmy Kimmel test” that all children would be ensured coverage. But Kimmel argues the provisions allowing waivers to states could put coverage out of the price-range of millions of Americans.

Which side will be more divided?

Graham and Cassidy are generally united on health-care policy as the authors of the latest repeal plan. But some Republicans have issues with it.

Sen. Rand Paul (R-Ky.) argued the proposal doesn’t go far enough in repealing ObamaCare and has said he won’t vote for it unless certain demands are met.

Among other things, he wants to substantially reduce the amount of funding states would be given through block grants. A number of states are already slated to lose funding under the bill, and cutting funding even more would further alienate moderates.

Sen. John McCain (R-Ariz.) announced his opposition to the bill Friday, saying Congress should return to “regular order” for health care changes.

Moderates like Sens. Susan Collins (R-Maine) and Lisa Murkowski (R-Alaska), who voted against the last repeal bill, haven’t come out against the bill, but have said they have concerns about its impact on their states.

A number of Republican governors have also opposed the bill, citing concerns about how it will impact their states.

On the other side, Sanders and Klobuchar support ObamaCare, but aren’t united on single payer. Klobuchar wasn’t one of the 16 Senate Democrats to co-sponsor Sanders’s “Medicare for all” bill last month.

How will Democrats defend ObamaCare?

Democrats have defended ObamaCare amid efforts from Republicans to dismantle it, but they’ve also acknowledged it needs improvements.

Klobuchar and Sanders will have to have good answers about the double-digit premium increases forecast for 2018.

They’re likely to point to what Democrats have described as “sabotage” from the Trump administration. Insurers across the country have hiked premiums for 2018 amid uncertainty over whether key ObamaCare payments called cost-sharing reductions will be paid.

Democrats also are likely to note that bipartisan efforts to lower premiums and stabilize ObamaCare’s insurance markets for next year were put on hold after the Graham-Cassidy proposal began to gather support in the Senate.

But the increasing costs of premiums has been a criticism of ObamaCare before President Trump was elected. Democrats might have to answer questions about what they would do to improve ObamaCare, while still trying to defend the law.

How will the moderators handle it?

ObamaCare is a testy issue that Democrats and Republicans have been unable to find compromise on in its seven years of being law.

It will be interesting to see what questions Bash and Tapper ask and if they’ll interject to correct the record.

Audience members will also be able to ask questions.

CNN said it selected audience members with varying political affiliations with a focus on those who would be impacted by the proposed repeal plan.

The GOP can’t quit Obamacare repeal because of their donors

https://www.vox.com/policy-and-politics/2017/9/25/16339336/graham-cassidy-republican-donors

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Graham-Cassidy has gained steam because many Republican senators care primarily about pleasing their donors.

Senate Republicans are trying yet again to repeal Obamacare, despite seemingly having all the political and substantive reasons in the world not to.

Like all the other bills, the newest one, sponsored by Sens. Lindsey Graham and Bill Cassidy, is horrendously unpopular, with only 24 percent support. The rushed and slipshod process around the bill means its consequences still aren’t well understood, but it’s clear enough that tens of millions of people would likely lose coverage if it passes, that several statesrepresented by Republican senators would lose billions of dollars in federal funding, and that the bill badly violates President Trump’s campaign promise not to cut Medicaid.

Instead of putting repeal to the side after its failure in the Senate in July, though, Republicans just keep coming back to it, and are pushing toward a Senate vote on Graham-Cassidy this week. They’re doing so in part because they feel obligated to fulfill a longtime campaign promise, and because they fear electoral consequences for being viewed as failures.

But one more crucial motivator explains a whole lot: Republican Party donors want it.

The evidence that the GOP is trying to please donors here is adding up. An anonymous Republican senator told Politico that McConnell might be returning to health care to show donors “that the Senate GOP tried again.” Senate Republicans were warned at a private meeting that fundraising was slow because donors were disappointed at their lack of accomplishments, per the New York Times. And in recent months, senators “faced an unrelenting barrage of confrontations with some of their closest supporters, donors and friends” over Obamacare repeal’s failure, according to the Washington Post.

This pressure seems to be able to move votes. One moderate senator, Dean Heller (R-NV), conspicuously switched from being a public critic of repeal efforts to a strong supporter of Graham-Cassidy. That came after he reportedly got an earful from Sheldon Adelson and Steve Wynn, two billionaire GOP donors in his state.

Steve Schmidt, who ran John McCain’s presidential campaign in 2008, told Vox recently that donor concerns seem to be dictating the GOP’s legislative strategy. “There’s not an actual human constituency for any aspect of the Republican Congressional agenda,” Schmidt says. “Instead it’s an inside game that is judged, win or lose, on the basis of which entrenched permanent interests gain advantage or disadvantage, and how that affects the endless fundraising process.”

“You’re voting to reorganize one-sixth of the economy without any sense of how much it costs, or who it’s gonna affect, and with 13 percent approval of it at a national level,” Schmidt continues. “The drivers of it are something other than the voters.”

And if you assume the goal of passing repeal is primarily to please donors and goose fundraising, a whole lot about congressional Republicans’ bizarre approach to repeal — particularly, their disinterest in policy details or in how restructuring the health system will impact their constituents — makes a lot more sense.

What, exactly, do these donors want?

One interesting feature about this donor pressure Republicans are facing is that it does not appear to be coming from insurance companies or other health care industry stakeholders hoping to profit greatly from changes to the Affordable Care Act. (Health industry lobbyists in fact have been caught by surprise by the Graham-Cassidy boomlet.)

Instead, it appears to be a sentiment broadly shared among much of the GOP donor class. Paul Kane, who wrote a Washington Post report on pressure Republican senators faced after their initial failure on repeal, tweets that he’s heard “local Chamber types” or “longtime supporters” who’ve donated to them for years were particularly influential.

But super-wealthy donors are making their voices heard too. Doug Deason of Texas, who is part of the Koch brothers’ donor network, said earlier this year that his “piggy bank” would be closed until congressional Republicans “get some things done,” according to the Associated Press.

In trying to understand why these donors want Obamacare repeal so badly, I think it’s helpful to think of two somewhat overlapping sets of motivations.

The first is, essentially, a desire for their political “team” to win. These donors have been funding GOP candidates for years, and those candidates have been campaigning on repealing Obamacare. And while they may not care all that much about health policy, they care about broader matters like whether the Republican Party can get things done, or whether they feel their team is fighting for its principles.

Ken Vogel, who’s covered megadonors for years at Politico and now the New York Times, has said that he thinks a lot of them “treat this almost like a hobby” or game that they’re trying to win. “These folks have all this money, and they’re doing something they believe in. If they win, great; if they don’t win, they had fun doing it.”

In this case, the donors spent on the 2016 election, won, and now feel they’re owed a prize. If they don’t get a prize, then, well, they might not be so eager to open their wallets again. However, they don’t have particularly strong views or interests in the details of Obamacare repeal or how it should be replaced — so it makes sense that many Republican senators channeling their views would be similarly indifferent to what their bill actually does.

The ideological motivation: Obamacare repeal is the best chance to slash government spending

But a second set of donor motivations — that do help explain one major feature of nearly all the repeal bills we’ve seen — are ideological.

Across nearly every major version of Obamacare repeal that the House and Senate considered this year, there’s been one constant: hundreds of millions of dollars on cuts to government spending on health insurance. (Even the massive tax cuts for the wealthy in earlier versions of the bill were eventually scaled back to protect these spending cuts.)

The persistence of these cuts has been odd. If the GOP’s goal was simply to pass something, scaling back the cuts could have helped improve coverage numbers and win over wavering moderates. Furthermore, the bills’ deep cuts to traditional Medicaid go beyond merely rolling back Obamacare, as well as violating President Trump’s campaign promises not to cut that program.

These cuts make a whole lot more sense, though, when you view them as part of a long-term ideological project.

In addition to more traditional business and corporate donors, the GOP gets a great deal of its financial backing from megadonors with ideological motivations, like Charles and David Koch. These donors just don’t want to feel good by winning — they want to dramatically shrink the size of the federal government. And the way that’s done is by cutting spending.

In recent years, they’ve had little success. President George W. Bush found it to his political benefit to hike spending, and Donald Trump promised to protect entitlement programs. While an appealing slogan in the abstract, cutting spending usually proves to be difficult and unpopular in practice.

But Obamacare repeal is different, politically. It’s tied to the despised (on the right) figure of Barack Obama, it can be sold as a fix for the health system’s woes more generally, and the entire Republican Party (including the president) have campaigned on it for years. And it can be done through the budget reconciliation process.

As such, it’s clearly the Republican majority’s best chance for enacting deep spending cuts — and a fantastic Trojan horse if that is the true goal of some of their donors.

Dean Heller looked like he’d stop repeal in his tracks. Then he changed his mind.

Now, as Republicans are facing a tough fight to hold onto Congress in 2018, they’re reportedly finding that fundraising is more difficult than they’d expected.

Sen. Cory Gardner (R-CO), who runs the Senate GOP’s fundraising arm, warned his colleagues at a lunch two weeks ago that their legislative failures, including on Obamacare repeal, were badly hurting fundraising. That’s according to a fascinating report by the New York Times’ Carl Hulse, who writes:

[Gardner] warned that donors of all stripes were refusing to contribute another penny until the struggling majority produced some concrete results.

“Donors are furious,” one person knowledgeable about the private meeting quoted Mr. Gardner as saying. “We haven’t kept our promise.”

Donor influence has been the most obvious in the case of Sen. Dean Heller.

Heller is facing a tough reelection fight in 2018. Hillary Clinton won his state, which also happens to have benefited greatly from Obamacare’s Medicaid expansion. Naturally, then, Heller was hesitant to support an Obamacare repeal bill that would gut Medicaid. So in June, he publicly announced his opposition to one version of the Senate health bill alongside Nevada’s popular moderate Republican Gov. Brian Sandoval.

What happened right afterward, according to a report by the New York Times’ Jonathan Martin and Kenneth Vogel, was that two Nevada billionaires and leading GOP donors let him know that they were very unhappy with him:

Mr. Adelson and Mr. Wynn, two of Las Vegas’s leading gambling titans, each contacted Mr. Heller at the request of the White House last week to complain about his opposition to the Republican-written health overhaul, according to multiple Republican officials.

One ally of Mr. Heller’s acknowledged that Mr. Adelson and Mr. Wynn were unhappy with the senator at the moment and that their relationship needed some repair work.

Soon after this, Heller’s approach to the issue changed dramatically. He stopped sticking his neck out with public opposition. And though he did vote no on two versions of the Senate’s bill in July, he was willing to vote yes when it really counted, on the “skinny repeal” bill. Then, to rebuild his conservative cred further, he added his name to the Graham-Cassidy repeal proposal.

Now, with Graham-Cassidy becoming essentially the Senate GOP’s main repeal plan, Heller doesn’t even seem to be considering a no vote — even though, like the version of the bill he opposed back in June, this bill would make deep cuts to Medicaid and is opposed by Gov. Sandoval.

Heller likely didn’t change his mind only because of annoyed billionaires. After all, in August, Nevada business executive Danny Tarkanian announced he would challenge Heller in the Republican primary, presenting a threat to his right. Since President Trump is still quite popular among GOP primary voters, defying him may have seemed increasingly dangerous after that.

But as Heller runs for reelection in what’s expected to be a hugely expensive race, it would certainly be nice if he had the backing of a pair of deep-pocketed billionaires who can donate unlimited amounts to outside groups who will run ads supporting his candidacy, both in the primary and the general. And his political logic seems to be shared by most of the Senate GOP.