https://www.thefiscaltimes.com/2017/07/28/Health-Care-Fight-Isnt-Over-Despite-Democratic-Cheering

There was an air of finality to things in the Senate early Friday morning when Arizona Sen. John McCain crossed party lines to join Maine’s Susan Collins and Alaska’s Lisa Murkowski in killing a last-ditch attempt by Republican leadership to pass and Affordable Care Act repeal bill.

The headline above New York Times columnist David Leonhardt’s byline Friday morning was, “Phew: The Health Bill Fails.” But as a sleep-deprived Washington crawled out of bed several hours later, reality began to creep back into the picture. The fight over the ACA isn’t over; the battlefield has just changed.

The vote in the early hours of the morning had been on a measure that Republican leadership only made public a couple of hours before they expected to call the roll. Dubbed a “skinny repeal,” it was a mishmash of policies that even some senators who voted for it viewed with disgust. On Thursday afternoon, for example, South Carolina’s Lindsey Graham derided the bill as “horrible policy” and “a fraud.”

The bill would have repealed the individual insurance mandate imposed by the ACA, and in a nod to the arcane rules of the process Republicans were using to try to ram it past Democratic objections, it also repealed the employer mandate, but only for eight years. It contained other sops to elements of the GOP base, like a one-year ban on payments to Planned Parenthood from Medicaid, and the delayed implementation (for only three years?!) of a tax on medical devices.

A Congressional Budget Office score had promised that if the bill became law, millions of Americans would lose health insurance and those who were still able to buy it through the individual market would pay much higher premiums. For a considerable number of Republicans who voted for it, the hope was that the bill would never become law, but would force the House of Representatives to sit down in a conference committee and begin crafting a replacement.

For some senators, hope wasn’t enough. Graham, McCain, Wisconsin’s Ron Johnson and Louisiana’s Bill Cassidy, in a press conference Thursday afternoon, said they couldn’t vote for it without express assurances from the House that it wouldn’t simply accept the Senate measure as written and vote to send it to the president.

A vague statement from Ryan released after their remarks was enough for the others, but not for McCain, who scuttled the bill with his “no” vote and a dramatic thumbs-down in the wee hours of Friday morning.

Senate Majority Leader Mitch McConnell was visibly frustrated with the conclusion of his months-long effort to find a repeal bill that could gather 50 votes in his conference. In remarks afterward, he expressed “regret” that the Senate had failed to achieve its goal, before adjourning until Monday, when he said lawmakers would take up some of the president’s judicial appointments.

But it wasn’t long before a tweet from President Trump reminded everyone that last night’s vote was nothing like the final curtain in the ACA drama.

Trump has long been promising to “let Obamacare implode,” arguing that doing so would strengthen his negotiating position even as it harmed the American people. And the drawn-out struggle over the GOP’s attempt to craft a legislative replacement for the law, or even to just repeal it with a promise to come back and replace it later, has often obscured the fact that he is well-positioned to just that if he chooses to.

The ACA’s original structure has already been partially dismantled, with payments to insurers that were part of the original bill suspended and insurance companies responding with higher premiums and lower deductibles. Other parts of it were never implemented it at all. Some large states, like Texas and Virginia, have refused to take part in the law’s Medicaid expansion, which would have provided millions of Americans with health care that they cannot currently afford.

Given that wobbly foundation, it wouldn’t take much prodding to tip the whole system over, and the president has all the tools he needs to do that.

Trump has already shown an interest in two of them.

First, he could publicly and explicitly direct the Internal Revenue Service to redirect enforcement efforts away from the individual mandate that is a core part of the ACA. By requiring people to carry an insurance policy or face a financial penalty, the mandate helps balance the pool of people insured in the individual market by including both healthy individuals who might only need expensive health care in an emergency, and unhealthy people in need of expensive chronic care.

In a system where insurers are required to issue policies to all applicants, that mix is essential to avoid a “death spiral” of ever-sicker risk pools forcing insurers to charge ever-higher premiums until the market collapses.

Second, Trump could order his administration to cease making Cost Sharing Reduction payments to insurers. The payments are meant to compensate insurance companies for the cost of providing policies to lower-income Americans, but they have been challenged as unconstitutional by the Republican House of Representatives.

The administration has already put the insurance industry on edge by making the payment of the CSRs almost a month-to-month decision. Eliminating them entirely would drive many insurers out of the marketplace and would cause others to raise premiums to unsustainable levels.

In other words, those who think the battles over the ACA are finished are deluding themselves.

http://khn.org/news/mccain-votes-no-derails-skinny-repeal-in-marathon-session/?utm_campaign=KHN%3A%20First%20Edition&utm_source=hs_email&utm_medium=email&utm_content=54732817&_hsenc=p2ANqtz–k_RyjnrsV5I3OytT1xGTiBIWnlNlMSYdyr5kwTt0JGgLaodLbaU2ev3Wam6ReA9qmZGmMuhZW58niwFrwiz5mc2divg&_hsmi=54732817

Sen. John McCain (R-Ariz.), who interrupted brain cancer treatment to return to Capitol Hill and advance the health law repeal efforts, cast the dramatic and decisive “no” vote in the early morning hours that upended the Republican effort to repeal the Affordable Care Act.

The Senate struggled late into the night to craft and then vote on a so-called “skinny repeal” of the health law, but came up empty as the bill was defeated in a 51-49 vote that prompted gasps in the chamber. McCain’s vote was unexpected and ends — for now — the Republican party’s effort to kill Obamacare.

Sens. Lisa Murkowski (R-Alaska) and Susan Collins (R-Maine) cast the two other Republican “no” votes in a cliffhanger drama that ended just before 2:00 a.m. Friday.

Earlier, a group of Republican senators trashed the new measure, widely dubbed a “skinny repeal,” saying it would only worsen the health care system, and they demanded unprecedented promises from their House colleagues to change it.

“The skinny bill in the Senate doesn’t even come close to honoring our promises of repealing Obamacare,” said Sen. Ron Johnson (R-Wis.). “Virtually nothing we’re doing in any of these bills and proposals are addressing the challenges, the problems, the damage done [by the Affordable Care Act].”

Staff of Senate Majority Leader Mitch McConnell (R-Ky.) crafted the new bill, which was under discussion all afternoon and posted publicly late Thursday evening.Senate Majority Leader Mitch McConnell goes on and off the Senate floor during an all-night session to consider the Republican healthcare bill. (Photo by Melina Mara/The Washington Post via Getty Images)

The slimmed-down version of the Senate bill — The Health Care Freedom Act, which the White House refers to as the “freedom bill” —included an end to key elements of the health law. Among them were rollbacks of the mandates for individuals and employers to buy health insurance, changes to waivers available under Section 1332 of the ACA that would give states more leeway to alter essential benefits in insurance plans, and a repeal of the medical-device tax.

It was not immediately clear how the bill achieved savings similar to $133 billion in the House’s version of repeal legislation. An equal or better level of savings is required under the arcane budgetary process that is being used to advance the bill, known as reconciliation.

Budget reconciliation allows the measure to pass the Senate on a simple majority vote, but requires that all of its provisions pass muster with the Senate parliamentarian as budget-related. The text of the bill posted publicly at 10 p.m. The CBO report on it began circulating on Twitter around midnight and the vote finally closed around 1:45 a.m. Friday.

One provision that had been restored after the parliamentarian initially struck it was an attempt to defund Planned Parenthood for a year. The new provision took in at least one additional abortion provider, and was expected to survive. The funding for Planned Parenthood was to be shifted to community health centers.

Keeping the attack on Planned Parenthood solidified Murkowski and Collins’ opposition to the vote.

This new iteration of the repeal comes after two versions failed to win over the 50 GOP senators needed. But even with all the rewriting and behind-the-scenes negotiation, four senators called a press conference to declare they will not vote for this “skinny repeal” unless House Speaker Paul Ryan (R-Wis.) promises not to merely pass the measure but send it to a conference committee between the two chambers, where it can be substantively altered.

The four senators slammed the trimmed-down compromise.

“I am not going to vote for a piece of legislation that I believe is not a replacement, that politically would be the dumbest thing in history to throw this out there,” said Sen. Lindsey Graham (R-S.C.).

Left to right, Sens. Lindsey Graham (R-S.C.), Bill Cassidy (R-La.), Ron Johnson (R-Wis.) and John McCain (R-Ariz.) hold a news conference Thursday to say they would not support the “skinny repeal” legislation unless it was guaranteed to go to conference with the House. (Photo by Chip Somodevilla/Getty Images)

He said that he, Johnson and McCain and Sen. Bill Cassidy (R-La.) would not vote for the skinny repeal until Ryan pledges to “go to conference,” where Graham can include a measure to shift current Obamacare funding into a block-grant program for states.

His fear, Graham said, is that the House might simply take up and pass the skinny repeal in order to be done with it and notch a win in their seven-year battle against Obamacare.

Graham referred to estimates that said the repeal of the ACA mandates would “collapse the individual market” and leave the GOP to “own the problem at a time when Obamacare is collapsing.”

Ryan did release a statement with a conditional promise to take the bill to conference. Initially, it did not satisfy Graham or McCain. Graham and Johnson were persuaded, however, after a phone conversation with Ryan. McCain was not.

For their part, Democrats uniformly panned the GOP’s efforts.

“We’ve had one bad bill after another. There is no bill that is a good bill,” said Sen. Dianne Feinstein (D-Calif.). “Every bill takes people off health care. Every bill makes you pay more for less. There’s a race to the bottom, so to speak.”

Sen. Chris Murphy (D-Conn.), hammered the entire process: “This is nuclear grade bonkers.”

http://thehill.com/policy/healthcare/344268-senate-defeats-obamacare-repeal-measure

http://thehill.com/homenews/senate/344270-mccain-votes-to-kill-gops-skinny-backup-obamacare-repeal-plan

Sen. John McCain (R-Ariz.) cast the crucial surprise vote that killed the last-resort Senate Republican ObamaCare repeal bill early Friday morning in a shocking moment that at least temporarily ended the GOP’s hopes of eliminating the former president’s signature law.

Voting shortly after midnight, McCain — who returned to the Senate on Tuesday after undergoing emergency surgery related to brain cancer — joined GOP Sens. Susan Collins (Maine) and Lisa Murkowski (Alaska) in opposing the measure that would have repealed key parts of ObamaCare.

McCain cast the “no” vote two days after a dramatic return to the Senate floor during which he called on his colleagues to work together on major issues such as healthcare reform, which has long been a Senate tradition until the upsurge of partisanship in recent years.

The vote cements McCain’s status as the Senate’s maverick, a role he relished earlier in his career when President George W. Bush occupied the White House.

McCain, who was defeated in the 2008 presidential election that brought Barack Obama to power, has emerged this year as one of President Trump’s most outspoken critics in Congress.

The two feuded during Trump’s presidential campaign; at one point, Trump mocked McCain for being a prisoner of war, saying he liked war heroes who were not captured.

That history simply added to the drama of Friday morning’s moment.

The bare-bones healthcare proposal, dubbed the “skinny” repeal because it left untouched big sections of ObamaCare, would have resulted in 16 more million people being without insurance in a decade, according to the Congressional Budget Office (CBO).

The CBO also estimated that it would increase premiums by 20 percent compared to current law.

Given those statistics, there was speculation early in the week about whether McCain would vote with his party given his own health news.

McCain did vote with Republicans to start debate on Tuesday, but warned he was opposed to the current version of their repeal-and-replace legislation.

He warned on Thursday that he did not want the skinny bill to become law, and asked for assurances from House Speaker Paul Ryan (R-Wis.) that there would be a conference and that the House would not just pick up the skinny bill and pass it.

Other senators aligned with him appeared reassured by a Ryan statement and backed the skinny bill. But McCain appeared to feel differently with his own vote.

Senate Majority Leader Mitch McConnell (R-Ky.) pushed the skinny bill as a backup proposal after Republicans failed to agree on a bigger repeal that repealed and replaced the pillars of ObamaCare or a repeal-only measure that passed both chambers in 2015.

He appeared almost distraught after McCain’s surprise vote and seemed close to choking up on the floor after falling short of his promise to repeal ObamaCare.

“This is clearly a disappointing moment,” he said.

“I regret that our efforts were simply not enough this time. Now, I imagine many of our colleagues on the other side are celebrating. Probably pretty happy about all this. But the American people are hurting, and they need relief.”

Many Republican senators, however, did not support the substance of the so-called skinny legislation. They decided to vote for it as a way to prolong the healthcare negotiation by setting up a conference negotiation with the House.

Still, McCain’s vote surprised many Republicans including Sen. Bill Cassidy (La.), who said he thought the Arizona Republican was in favor of the legislation.

Sen. Ron Johnson (R-Wis.) told reporters, “I’m shocked at this.”

Vice President Pence was spotted lobbying McCain on the Senate floor shortly before the crucial vote. He also worked on Collins while other GOP leaders focused on Murkowski.

But those efforts fell short.

Senate Republican Conference Chairman John Thune (R-S.D.) said McCain was wrestling with the decision all day but in the end would not budge.

“He had made up his mind and I’m not sure there was much that could have been done about it,” he said.

McCain declined to “go through my thought process” when reporters asked him about his vote.

Whatever he may have thought about, the diagnosis of brain cancer he received from doctors last week hovered over his decision.

None of his colleagues mentioned it explicitly, but many Democrats thought it would be a sad irony if the lawmaker voted for legislation that CBO projected would cause 16 more million people to be without health insurance at a time when he was depending on doctors in his fight against cancer.

In addition, McCain was never a big fan of the Senate healthcare reform effort, which would have cut billions of dollars in Medicaid funding for his home state of Arizona, one of 30 states that expanded enrollment under ObamaCare.

He raised Republican suspicions and Democratic hopes shortly before the historic vote when he declined to tell reporters how he would vote on the latest idea from the GOP leadership, the so-called “skinny” repeal.

One Republican leadership source predicted earlier in the day that it had a “nine out of 10” chance of passing.

But McCain’s defection became apparent when he began huddling with Democrats on the Senate floor.

He complained earlier this month after Senate GOP leaders left out three Medicaid-related amendments that Arizona Gov. Doug Ducey (R) asked to be included in the bill.

McCain joined GOP Sens. Lindsey Graham (S.C.), Ron Johnson (Wis.) and Cassidy at a press conference a few hours before the vote in which they asked for assurances from House GOP leaders that the “skinny” bill would be revised substantially in a conference negotiation with the House.

Ryan tried to provide some assurance by telling senators that he was willing to work with them, but a Ryan spokesperson earlier in the day described a conference negotiation as an “option” but not a certainty.

“If moving forward requires a conference committee, that is something the House is willing to do,” Ryan said in a statement.

But McCain told reporters that pledge did not go far enough.

“I would like to have the kind of assurances he did not provide,” he said.

Four GOP senators threaten to block ‘skinny’ repeal

Four GOP senators — enough to kill the legislation — say they need hard assurances from House Speaker Paul Ryan that a “skinny” ObamaCare repeal bill won’t be Congress’s final product before they’ll vote for it.

Sens. John McCain (Ariz.), Lindsey Graham (S.C.), Ron Johnson (Wis.) and Bill Cassidy (La.) said Thursday evening they are prepared to vote against a skinny repeal unless they get a guarantee it will go to a conference committee with the House.

“There’s increasing concern on my part and others that what the House will do is take whatever we pass” and pass it without making changes, Graham said.

“The skinny bill as policy is a disaster. The skinny bill as a replacement for ObamaCare is a fraud,” he said. Graham added that if the skinny bill passes the House, the GOP will own the collapse of ObamaCare.

“I’d rather get out of the way and let it collapse than have a half-assed approach where it is now our problem,” he continued.

If the skinny bill were to become law, insurers and other healthcare groups have warned it could cause premiums in Obamacare’s insurance markets to skyrocket.

Graham said a conference committee would buy time for the Congressional Budget Office (CBO) to score proposals from himself and Cassidy, as well as by Sen. Rob Portman (Ohio) and Ted Cruz (Texas).

When asked how he’d know any assurance from House leadership is ironclad, Graham said, “It’s like pornography, you know it when you see it.”

If the Senate does pass a bill, both chambers would have to approve whatever emerges from the House-Senate conference. Alternatively, the House could simply approve the Senate’s skinny bill — a prospect that prompted the press conference from the four GOP senators.

Nothing has been determined yet in the House; GOP leaders appear to be keeping their options open and could call up the bill any time between now and Tuesday.

Senate Majority Whip John Cornyn (R-Texas) said he has had no formal assurances from the House, but has every expectation a conference committee will be called.

“There has been some communication in which it has been reported to me that Paul Ryan said the House is preparing to go to conference,” Cornyn said, noting, “I have not talked to Paul Ryan. The Senate doesn’t determine whether the House goes to conference.”

A spokeswoman for Ryan said the House hadn’t yet decided its course of action.

“Conference Committee is one option under consideration and something we’re taking steps to prepare for should we choose that route after first discussing with the members of our conference,” AshLee Strong said.

GOP leaders have not yet revealed their scaled-down measure, but it is expected that it would repeal the employer and individual mandates from ObamaCare.

In another key provision to win conservative support, it would also block federal funding for Planned Parenthood, which provides abortion services. The skinny bill could also cut ObamaCare’s prevention and public health fund, while adding money for community health centers, sources said.

It would not cut Medicaid, which has been a concern for centrist Republicans. However, conservatives could add the Medicaid cuts back into the bill during a conference committee.

It’s not clear when the Senate will take a final vote on the skinny measure, but Republicans can only afford two defections and still rely on Vice President Pence to break the tie.

The bill is expected to be the final amendment at the end of a marathon voting session beginning Thursday evening.

House Majority Leader Kevin McCarthy’s (R-Calif.) office has warned House lawmakers that they should not immediately depart Washington on Friday, in case the Senate does approve a repeal bill.