No, Trump Hasn’t ‘Essentially Repealed Obamacare’

https://www.politico.com/magazine/story/2017/12/20/trump-obamacare-mandate-repeal-taxes-216125

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Killing the mandate doesn’t gut the health care law. Most likely, it will muddle along, because the rest of it is broadly popular.

In July and again in September, Republicans narrowly failed to repeal the Affordable Care Act. But their newly passed tax legislation included a provision getting rid of Obamacare’s mandate requiring Americans to buy insurance, and President Donald Trump immediately declared victory in the partisan health care wars. “When the individual mandate is being repealed, that means Obamacare is being repealed,” he crowed at a Cabinet meeting on Wednesday. “We have essentially repealed Obamacare.”

Well, no. The individual mandate is only part of Obamacare. It wasn’t even included in the original health care plan that Barack Obama unveiled during the 2008 campaign. The mandate did become an important element of Obamacare, and the only specific element that a majority of the public opposed. But the more generous elements of the program—like a major expansion of Medicaid, significant government subsidies for private insurance premiums, and strict protections for pre-existing conditions—are still popular, and still the law of the land.

“The death of Obamacare has been exaggerated,” says Larry Levitt, who oversees health reform studies at the Kaiser Family Foundation. “Eliminating the mandate creates uncertainty, but all the benefits for people remain in place.”

The Republican ecstasy and Democratic gloom over the death of the mandate reflects the most consistent misperception over the seven-plus years of Affordable Care Act debates, the incorrect assumption that the “Obamacare exchanges,” where Americans can buy private insurance, are synonymous with Obamacare. The vast majority of Americans who get their coverage through Medicare, Medicaid or their employers shouldn’t be affected. Yes, killing the mandate could cause problems for the remaining 6 percent of Americans who have to buy insurance on the open market, but nearly half will remain eligible for subsidies that would insulate them from any premium hikes.

Repealing the tax penalties for Americans who don’t buy insurance would not repeal Obamacare’s perks for Americans who do—like the ban on annual and lifetime caps that insurers previously used to cut off coverage for their sickest customers, or the provision allowing parents to keep their children on their plans until they turn 26. And it would not repeal Obamacare’s “delivery reforms” that are quietly transforming the financial incentives in the medical system, gradually shifting reimbursements to reward the quality rather than quantity of care. The growth of U.S. health care costs has slowed dramatically since the launch of Obamacare, and the elimination of the mandate should not significantly affect that trend.

In fact, during the 2008 campaign, Obama was the only Democratic candidate whose health plan did not include a mandate, because he was the only Democratic candidate who thought the main problem with health care was its cost. “It’s just too expensive,” he explained at an Iowa event in May 2007. Insurance premiums had almost doubled during the George W. Bush era, and Obama believed that was the reason so many Americans were uninsured. He doubted it would be worth the political heartburn to try to force people to buy insurance they couldn’t afford.

But Obama eventually embraced the argument that a mandate was necessary to ensure that young and healthy Americans bought insurance. The fear was that otherwise, insurance markets dominated by the old and sick (who would enjoy the law’s new protections for pre-existing conditions) would have produced even higher premiums, and might scare insurers away from serving Americans who don’t get coverage through their jobs or the government. Killing the mandate will be a step in that direction, boosting Trump’s heighten-the-contradictions effort to sabotage the functioning of Obamacare to build support for a more sweeping repeal.

That effort has already produced some damaging results for the exchanges. Insurers have increased their premiums for 2018, repeatedly citing uncertainty over Trump’s efforts to blow up Obamacare as well as his decision to cut off promised payments to insurers who cover lower-income families. Several insurers left the exchanges even before the elimination of the mandate, and others could follow.

But the widespread warnings that wide swaths of America would have no insurers on the exchanges were wrong; there are zero “bare counties” with no insurers for 2018. And a Kaiser review found the exchanges have gotten more profitable for insurers this year,despite Trump’s efforts to damage them. This year’s enrollment period appears to have gone fairly well even though the Trump administration shortened it by half and slashed its promotional budget.

The fear is that eliminating the mandate could produce a “death spiral” for the exchanges, where higher premiums scare away healthier customers, leading to even higher premiums and even sicker customers—until eventually,the insurers decide to bail. It could also encourage insurers to try to lure healthier customers with cheaper but skimpier plans that don’t provide protections for pre-existing conditions, since those customers would no longer have to pay a tax penalty.

But it is also possible that younger and healthier customers who initially bought insurance because they were required to do so will now buy insurance because they want to; surveys show that more than 75 five percent of Americans covered on the exchanges are happy with their coverage. And as a political matter, repealing the unpopular mandate could make it even harder for Republicans to pass legislation repealing insurance protections, Medicaid expansions and the rest of Obamacare, because the rest of Obamacare is popular. It’s not surprising that Republicans managed to kill the law’s vegetables, but it won’t be as easy to kill dessert.

Trump thinks congressional Democrats will soon be begging him to come up with a replacement for Obamacare, and even many Republicans who don’t embrace that fantasy believe the demise of the mandate will ratchet up pressure for a permanent solution to a seven-year political war. It could happen. But there hasn’t been a lot of bipartisanship in Washington lately, and after the Doug Jones upset in Alabama, it seems unlikely that a Senate with one fewer Republican will be more amenable to a Republican-only repeal bill.

The most likely outcome seems to be at least a few more years of Obamacare muddling through, and at least a few more years of Obamacare political warfare.

 

Tax Bill Threatens Our Health and Our Democracy

http://www.chcf.org/articles/2017/12/tax-bill-threatens-our-democracy

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Earlier this month, the Senate passed legislation that would overhaul the tax code, make dramatic changes to federal health care policy, and undermine the budgets of Medicaid and Medicare, two pillars of the American health care system. The House and Senate are now trying to reconcile their two tax bills. Each passed the legislation on a party-line vote, with one Republican voting against the bill in the Senate.

Congress is now one step away from passing a tax bill that will have a profound effect on the health and well-being of Americans for a generation. No one should forget that, to get this close, the Senate rushed to approve a deeply unpopular proposal with little transparency and due diligence — and no bipartisanship. Left unchecked, these actions will harm millions of Americans — and American democracy itself.

Even though the legislation has been framed as a tax bill, it is very much a health care bill. The Senate bill would eliminate the Affordable Care Act’s individual health insurance mandate, which would lead to the destabilization of the individual health insurance market. The Congressional Budget Office (CBO) projects that this change alone would increase individual premiums by 10% a year and cause as many as 13 million Americans to join the ranks of the uninsured by the end of the next decade. In California, the uninsured population would grow by 1.7 million people. Congress may still pass separate legislation to restore some stability to the individual market, but the leading proposals are too modest to prevent much damage.

Seismic Impact

On its own, the language in the tax bills would trigger a major earthquake in the health care system, and the aftershocks of this tax bill would be just as dangerous. By eliminating more than $1 trillion of federal revenue, the administration and congressional leaders are manufacturing a budget crisis that would likely lead to automatic cuts to Medicare under federal rules. The CBO, which examined the House bill, has estimated that those cuts could be around $25 billion a year. Republican leaders have also indicated they intend to use the revenue shortfall that they are engineering with this tax bill to seek deep cuts in safety-net programs, starting with Medicaid.

This isn’t merely about what the legislation will do to health care, because it also would exacerbate inequality and worsen health disparities in this country. Under both the House and Senate bills, low- and middle-income families would pay more in taxes and have a harder time paying not just for health care, but also for food, housing, child care, education, and other basic needs. When people struggle so much to make ends meet, they suffer more from illness and die younger. And if inequality keeps getting worse, it will undermine the economic, social, and political stability upon which our nation depends.

The burden on Californians would be particularly heavy. Our families would no longer be able to deduct what they pay in state and local taxes on their federal tax returns. This change alone would take more than $112 billion a year out of the pockets of hardworking Californians — more than any other state. The fact that Californians would be paying more in federal taxes would inevitably put new pressure on our state and municipal governments to reduce their taxes. Under that scenario, it is not hard to imagine a new wave of painful state and local budget cuts.

The irony is that California actually has the power to stop this runaway train. If the entire California congressional delegation worked together to protect their constituents, and if they were united and strong, they could prevent many — if not all — of the worst provisions in the tax bills from becoming law.

This moment is a test of leadership. Nothing less than the health of our people — and our democracy — are at stake.

Actuaries warn of premium increases from repealing ObamaCare mandate

http://thehill.com/policy/healthcare/364514-actuaries-warn-of-premium-increases-from-repealing-obamacare-mandate

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A group of insurance experts is warning Congress against repealing ObamaCare’s individual mandate, saying the move would raise premiums and could cause insurers to drop out of the market.

The American Academy of Actuaries wrote to congressional leaders on Tuesday saying that “eliminating the individual mandate would lead to premium increases.”

The Republican tax-reform bill which is nearing completion in Congress would repeal the ObamaCare mandate that people have health insurance or pay a fine.

Republicans argue the measure included in the Senate-passed bill is tax relief by removing a penalty for low-income people who choose not to buy insurance.

The actuaries warn that repealing the mandate would harm the health insurance market by removing an incentive for healthy people to enroll and balance out the costs of the sick.

The insurance experts also say that a measure pushed by Sen. Susan Collins (R-Maine), intended to help offset the premium increases from repealing the mandate, would not be enough to make up the difference.

That bill, sponsored by Sens. Lamar Alexander (R-Tenn.) and Patty Murray(D-Wash.), would fund key ObamaCare payments known as cost-sharing reductions. The actuaries say the payments “would not offset premium increases due to an elimination of the mandate.”

The letter says additional measures — such as funding to bring down premiums known as “reinsurance,” which Collins has also proposed — could help, though. Some experts say more funding than is currently proposed would be needed.

The instability from repealing the mandate also could lead some insurers to drop out of markets altogether, the actuaries warn, potentially leaving some people with no insurance options.

“Insurers would likely reconsider their future participation in the market,” the actuaries write. “This could lead to severe market disruption and loss of coverage among individual market enrollees.”

 

 

Actuaries: Alexander-Murray won’t offset mandate repeal

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The American Academy of Actuaries is throwing some cold water on Republicans’ claims that they’ll offset the damage from repealing the ACA’s individual mandate by restoring funding for the law’s cost-sharing subsidies.

  • “While making cost-sharing reduction reimbursements to insurers … would offset premium increases due to the prior termination of those payments, it would not offset premium increases due to an elimination of the mandate,” the actuaries wrote in a letter yesterday.
  • This should not come as a surprise. This is hardly the first time nonpartisan experts have said the move to restore cost-sharing payments — a bill sponsored by Sens. Lamar Alexander and Patty Murray — would not make up for the effects of repealing the mandate. They are separate things.

The big question: Does Collins believe this analysis, and does she care? Collins has made two ACA-related demands — a vote on Alexander-Murray, and a vote to establish a new reinsurance fund — in return for her vote to repeal the individual mandate.

  • Plenty of experts have said Alexander-Murray wouldn’t do much.
  • Reinsurance would.
  • But it’s not clear either proposal can pass the House. If one of them can, it’s probably Alexander-Murray.
  • That leaves a distinct possibility that insurance markets will not actually see the stabilizing effects Collins is bargaining for.

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Tax Bill Is Likely to Undo Health Insurance Mandate, Republicans Say

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House and Senate negotiators thrashing out differences over a major tax bill are likely to eliminate the insurance coverage mandate at the heart of the Affordable Care Act, lawmakers say.

But a deal struck by Senate Republican leaders and Senator Susan Collins of Maine to mitigate the effect of the repeal has been all but rejected by House Republicans, potentially jeopardizing Ms. Collins’s final yes vote.

“I don’t think the American people voted for bailing out big insurance,” said Representative Dave Brat, Republican of Virginia, who opposes a separate measure to lower insurance premiums that Ms. Collins thought she had secured.

The sweeping tax overhaul approved Saturday by the Senate would eliminate penalties for people who go without insurance, a change not in the tax bill passed last month by the House. But the House has voted many times to roll back the mandate, most recently in a bill to dismantle the Affordable Care Act, and House members were enthusiastic about going along.

“Mandating people to buy a product was a bad idea to begin with,” said Representative Rob Woodall, Republican of Georgia. “We made people do something that was supposed to be good for them. But they are telling us by the millions how much they dislike the mandate.”

The individual mandate was originally considered indispensable to the Affordable Care Act, a way to induce healthy people to buy insurance and thus to hold down insurance premiums for sicker customers. The Obama administration successfully defended the mandate in the Supreme Court. But recent economic research suggests that the effect of the mandate on coverage is somewhat smaller than previously thought.

With little more than a week remaining until the annual open enrollment period ends, 3.6 million people have selected health plans for 2018 in the 39 states that use the federal marketplace, the Trump administration reported Wednesday. That is 22 percent higher than at this point last year, despite uncertainty about the mandate’s future and efforts by Republicans and the administration to undermine the law.

But because the sign-up period is only half as long, it appears likely that enrollment will end up lower than in the last period.

Without a mandate, some healthy people are likely to go without coverage, leaving sicker people in the market, and prices are likely to rise more than they otherwise would. The Congressional Budget Office said last month that repealing the individual mandate would increase average premiums on the individual market about 10 percent, and it estimated that the number of people without health insurance would rise by 13 million.

Regardless, the requirement has proved to be one of the most unpopular parts of the 2010 law, and House Republicans were happy to see it go. Representative Richard Hudson, Republican of North Carolina, called the Senate provision “a great move.”

The repeal also frees up money that Congress can use to reduce tax rates. The budget office said it would save the federal government more than $300 billion over 10 years — mainly because fewer people would have Medicaid or subsidized private insurance.

The mandate repeal’s effect on health insurance markets did concern Ms. Collins, and to win her vote for the Senate tax bill, the Senate majority leader, Mitch McConnell of Kentucky, offered her a deal, in writing: He would support two bipartisan bills to stabilize markets and hold down premiums, in the absence of the individual mandate.

One bill would provide money to continue paying subsidies to insurance companies in 2018 and 2019 to compensate them for reducing out-of-pocket costs for low-income people. President Trump cut off the “cost sharing” subsidies in October, more than a year after a federal judge ruled that the payments were unconstitutional because Congress had never explicitly provided money for them. The payments would resume under this measure, drafted by Senators Lamar Alexander, Republican of Tennessee, and Patty Murray, Democrat of Washington State.

The second bill would provide $5 billion a year for grants to states in 2018 and 2019. States could use the money to help pay the largest health claims, through a backstop known as reinsurance, or to establish high-risk pools to help cover sick people.

Ms. Collins has released a copy of her agreement with Mr. McConnell in which he pledged to support passage of the two measures before the end of the year. His signature was displayed prominently at the top of the first page. But the deal has landed with a thud in the House, where Republicans appear loath to support legislation that they view as propping up a health law that they have pledged to repeal.

“Our members wince at voting to sustain a system that none of them supported,” said Representative Tom Cole, Republican of Oklahoma.

The Senate could attach the Alexander-Murray legislation to a government funding measure, hoping that Republicans in the House would be willing to swallow it as part of a measure to avoid a government shutdown. But Mr. Cole said House Republicans would be “very offended” at such an approach.

“I don’t think we’re in the mood to be blackmailed by anybody,” he said.

Mr. Brat, a member of the conservative Freedom Caucus, assailed the deal with Ms. Collins as an example of horse trading that is characteristic of the Washington swamp that he said voters had repudiated.

Likewise, Representative Mark Walker of North Carolina, the chairman of the conservative Republican Study Committee, said of the Alexander-Murray bill, “There’s no appetite for that over here.”

Ms. Collins said on Wednesday that she believed the House would “take a serious look” at the two bills intended to hold down insurance premiums and that Mr. Trump, in several recent meetings, had assured her that he also supported those bills.

“I don’t think this effort is over by any means,” Ms. Collins said.

For Democrats, eliminating the insurance mandate penalties provides yet another reason to oppose the tax bill.

“The individual mandate is at the heart of the Affordable Care Act,” said Representative James E. Clyburn, Democrat of South Carolina. “Repealing it, as the G.O.P. tax scam does, is a deliberate attempt to undercut the law, create chaos in the health insurance marketplaces, increase premiums and decrease choice and coverage.”

Ms. Murray indicated that even if Ms. Collins secures her deal, Democrats would remain steadfast.

“Our bill, the Alexander-Murray bill, was designed to shore up the existing health care system,” not to “solve the new problems in this awful Republican tax bill,” she said.

Meanwhile, the damage to the Affordable Care Act may already have been done. Daniel Bouton, an enrollment counselor in Dallas, said he worried that the Trump administration’s decision to cut advertising for open enrollment had prevented millions of people from learning about the shortened sign-up period. He also said that the Senate’s recent vote to undo the individual mandate as part of its tax bill would discourage people from signing up.

“You’re going to have people who say, ‘Well, perfect, I don’t have to buy insurance anymore,’” Mr. Bouton said.

 

Healthcare lobbyists not optimistic on changing GOP tax bill

http://www.modernhealthcare.com/article/20171206/NEWS/171209899

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Healthcare lobbyists are scrambling to win changes in congressional Republican tax legislation, as Senate and House GOP leaders race to merge their separate bills into something both chambers can pass on a party-line vote this month.

But provider, insurer and patient advocacy groups doubt they can convince Republicans to remove or soften the provisions they find most objectionable. They say GOP leaders are moving too fast and providing too little opportunity for healthcare stakeholders to provide input.

“It’s a madhouse,” said Julius Hobson, a veteran healthcare lobbyist with the Polsinelli law firm. “What you worry about is this will get done behind closed doors, even before they start the conference committee process.”

One factor that could slow the rush to pass the Tax Cuts and Jobs Act is the need to pass a continuing resolution this week to fund the federal government and prevent a shutdown. Unlike with the tax bill, Republicans need Democratic support for that, and it’s not clear they’ll make the concessions Democrats are demanding.

Industry lobbyists are particularly targeting provisions in the House and Senate tax bills limiting tax-exempt financing for not-for-profit hospitals and other organizations; repealing the Affordable Care Act’s tax penalty for not buying health insurance; ending corporate tax credits for the cost of clinical trials of orphan drugs; and taxing not-for-profit executive compensation exceeding $1 million.

If the ACA’s insurance mandate is repealed, “our plans will have to evaluate whether they can stay in the individual market or not based on what it does to enrollment and the risk profile of people who choose to stay,” said Margaret Murray, CEO of the Association for Community Affiliated Plans, which represents safety net insurers.

AARP and other consumer lobbying groups are fighting to save the household deduction for high healthcare costs, which the House version of the Tax Cuts and Jobs Act would abolish.

Healthcare lobbyists also are warning lawmakers that capping or ending the federal tax deduction for state and local taxes will force many states to cut Medicaid. Beyond that, they say slashing taxes and increasing the federal deficit will trigger immediate Medicare budget sequestration cuts that would hurt providers and patients, particularly in rural and low-income areas.

“One in three rural hospitals are at financial risk of closure, and sequestration would be devastating for them,” said Maggie Elehwany, vice president of government affairs for the National Rural Health Association. “I’d love to say our message is getting through. But Congress is completely tone-deaf on how troubling the situation in rural America is.”

Hospital groups, led by the American Hospital Association, are battling to preserve tax-exempt bond financing for not-for-profit organizations, which the House bill would zero out. While the Senate bill would keep the tax exemption for interest income on new municipal private activity bonds, both the Senate and House bills would prohibit advance re-funding of prior tax-exempt bond issues.

Hospitals say ending or limiting tax-exempt bond financing would jack up their borrowing costs and hurt their ability to make capital improvements, particularly for smaller and midsize hospital systems. The Wisconsin Hospital Association projected that ending tax-exempt bond financing would increase financing costs by about 25% every year.

According to Merritt Research Services, outstanding end-of-year hospital debt totaled nearly $301 billion in long-term bonds and nearly $21 billion in short-term debt. Nearly all of that debt was issued as tax-exempt bonds.

Suggesting a possible compromise, Rep. Kevin Brady (R-Texas), chairman of the House Ways and Means Committee, said Tuesday that he saw “a good path going forward” to preserve tax-exempt private activity bonds “that help build and enhance the national infrastructure.”

But Hobson raised questions about Brady’s comments. “What is his definition of infrastructure?” he asked. “It suggests they may move away from a blanket repeal, but it doesn’t tell me where they’re going.”

If Republicans decided not to repeal the tax exemption for municipal bond interest income, however, they would have to scale back some of their pet tax cuts for corporations and wealthy families, even as they feel pressure to ease unpopular provisions such as ending the deductibility of state and local taxes. That could make it hard for hospital lobbyists to gain traction on this issue.

“There are a lot of giveaways in the bills that don’t leave a lot of room to recoup the money you lose,” Hobson said.

Some lobbyists hold out a faint hope that the Republicans’ tax cut effort could collapse as a result of intra-party differences, as did their drive to repeal and replace the Affordable Care Act.

One possibility is that Maine Sen. Susan Collins flips and votes no on the tax cut bill emerging from the conference committee if congressional Republicans fail to pass two bipartisan bills she favors to stabilize the individual insurance market.

Collins said she’s received strong assurances from Senate Majority Leader Mitch McConnell and President Donald Trump that they will support the bills to restore the ACA’s cost-sharing reduction payments to insurers and establish a new federal reinsurance program that would lower premiums.

But the fate of those bills is in doubt, given that House Speaker Paul Ryan (R-Wis.) was noncommittal this week, while House ultraconservatives have come out strongly against them.

Collins conceivably could be joined by Alaska Sen. Lisa Murkowski, who also said she wants to see the market stabilization bills passed. If Tennessee Sen. Bob Corker, who voted no on the tax cut bill over deficit concerns, remains opposed, those three GOP senators could sink the tax bill.

“We’d all like to see Collins pull her vote,” Hobson said. “It was always clear that the deal she cut with McConnell won’t fly on the House side.”

One healthcare lobbyist who didn’t want to be named said there may be a deal in the works for House conservatives to support market-stabilization legislation in exchange for lifting budget sequestration caps on military spending.

But healthcare lobbyists are not holding their breath on winning major changes or seeing the tax bill collapse.

“There are chances they won’t reach a deal,” said Robert Atlas, president of EBG Advisors, which is affiliated with the healthcare law firm Epstein Becker Green. “By the same token, Republicans are so determined to pass something that they might just come together.”

Collins’ Obamacare deal faces moment of truth

https://www.politico.com/story/2017/12/08/susan-collins-obamacare-deal-213254

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House conservatives thumb their nose at the Maine moderate’s bid to slow the demise of the health law.

Sen. Susan Collins is barreling toward yet another health care showdown with her own party. But this time, she might not have the leverage to get what she wants.

Republicans who watched Collins lead the rebellion over the GOP’s Obamacare repeal effort just three months ago are playing tough on yet another high-stakes bill, wagering they can do without the Maine moderate’s swing vote and still claim a narrow year-end legislative win on tax reform.

Collins went along with the tax bill that repeals Obamacare’s individual mandate after Senate Majority Leader Mitch McConnell pledged to pass a pair of bills propping up Obamacare’s shaky insurance markets, including a bipartisan deal resuming payments on key subsidies that President Donald Trump halted in October.

But Speaker Paul Ryan has made clear he’s not bound by the deal, and there’s little urgency among House Republicans to do much of anything on health care before the end of the year. On Thursday, Republican Study Committee Chairman Mark Walker said conservatives received assurances that talks on a spending package to keep the government open won’t address Obamacare.

“The three things we were told are not gonna happen as part of our agreement: no CSRs, no DACA, no debt limit,” he said, referring to efforts to fund Obamacare’s cost-sharing subsidies.

That could cost Collins’ support after she signaled that her vote on the final bill may hinge on the fate of the health care measures.

She told a Maine CBS affiliate Thursday night that she’d wait to see the final language from the conference committee working on the tax bill before committing her vote.

“I won’t make a final decision until I see what that package is,” Collins told CBS WABI 5.

One bill, known as Alexander-Murray, would temporarily restore subsidies to insurers. The second would fund a two-year reinsurance program helping health plans cover particularly expensive patients.

Senate Republicans can only afford two defections and still pass the tax bill using a fast-track procedure that requires a simple majority, with Vice President Mike Pence ready to cast the tie-breaking vote. The margin would become razor thin if Collins holds out, and Sen. Bob Corker maintains his opposition over concerns about the bill’s impact on the deficit.

Yet House Republicans still chafing over the Senate’s failure to repeal Obamacare insist they won’t bend to Collins’ demands. And while Senate Republicans are trying to keep Collins in the fold, there’s little apparent worry so far that her opposition would sink the tax effort.

“I think you guys have to find something else to be concerned about,” said Sen. Tim Scott, one of the 17 GOP lawmakers assigned to merge the House and Senate versions of the tax plan.

Sen. Lamar Alexander, who coauthored Alexander-Murray and has championed its inclusion in a year-end agreement, also waved off the need to pressure House Republicans on the issue.

“The House knows our position,” he said. “When they see that they can lower premiums 18 percent … reduce the debt, reduce the amount of money going to Obamacare subsidies, I think it’ll be a Christmas present they’ll want to give to their constituents.”

One of the few moderates in a Republican conference that narrowly controls the Senate, Collins has regularly used her voice and vote to extract concessions from GOP leaders and ensure she’s a central figure in negotiations.

During the health care debate, she urged the GOP to protect Medicaid and preserve more subsidies for people to buy insurance. When they stuck with their blueprint, Collins joined fellow Republicans Lisa Murkowski and John McCain in a dramatic vote that killed the months-long repeal bid.

And in the run-up to the Senate’s late-night tax vote, she secured three late changes to the bill, including the expansion of a provision allowing people to deduct hefty medical bills that House Republicans had voted to eliminate entirely.

That was on top of McConnell’s “ironclad commitment” to tackle the two health care bills at year’s end — measures that Collins claims will help offset premium increases stemming from the bill’s repeal of Obamacare’s mandate that most Americans be insured.

Collins said Thursday she considers House passage of those Obamacare bills part of that commitment, even though McConnell has only publicly agreed to “supporting passage” of them and can’t singlehandedly force the House to take up legislation.

Ryan hasn’t officially ruled out the possibility, but declined to commit to rolling either of the bills into upcoming spending agreements. Conservatives have loudly opposed any aid for Obamacare, and even moderates who support stabilizing the health law have shrugged at the exact timing.

“What the vehicle is to get it through the system, in the House and the Senate to the president’s desk, I’ll leave that to our leadership,” said Rep. Tom Reed, who co-chairs the bipartisan Problem Solvers Caucus.

Collins insists she’s taking the long view, claiming progress Thursday on trying to win over House Republicans during rounds of private negotiations.

“I remain confident, despite your skepticism, that we will eventually get that,” she said.

And as the GOP learned during the repeal debate, the whip count could shift suddenly. Sens. Jeff Flake and Ron Johnson remain wild cards, and either could conceivably join Corker and Collins in torpedoing the tax bill if they dislike the final version.

For now though, Republican leaders are signaling once again that Collins may not get everything she wants on health care — and gambling it won’t cost them a second time.

“I think that these are separate issues,” said Sen. David Perdue. “I’m hopeful that that won’t derail this [tax bill]. We’ve got to get it this done and get it on the president’s desk.”