http://www.rollcall.com/news/white-house-health-care-implode

Amid pleas from Republicans and Democrats for the parties to begin work on a bipartisan health care bill, President Donald Trump and White House officials on Friday doubled down on his call to put off any action until Barack Obama’s 2010 law fails.

Ailing Arizona Republican Sen. John McCain shocked senators from both parties early Friday morning when he voted against a GOP leadership-crafted measure that amounted only to a partial repeal of the Affordable Care Act. Back in Washington after a brain tumor diagnosis, McCain made clear his vote was a shove for the entire Senate to get back to “regular order” — meaning hearings and floor debate — on health care and every other issue.

Following McCain’s dramatic vote on the Senate floor, several senators reported that Health, Education, Labor and Pensions Chairman Lamar Alexander of Tennessee is planning for just that. And Senate Minority Leader Charles E. Schumer, D-N.Y., said he saw Alexander and the committee’s ranking Democrat, Patty Murray of Washington, already talking in the wee hours of Friday morning.

“Now Republicans have a choice to make,” Murray said. “They can continue to try to bring Trumpcare back just to score political points and give special interests a massive tax break, or they can engage in the open, transparent, bipartisan process that many Democrats and Republicans agree is the right way to actually make our health care system work better for the people we serve.”

The list of committees that could begin health care-related work also includes the Homeland Security and Governmental Affairs panel. Its chairman, Ron Johnson of Wisconsin, at times has been very critical of the Senate GOP leaders’ process — which included no committee work and various bills crafted behind closed doors — despite his vote in favor of the so-called “skinny” repeal amendment.

“In the coming weeks, my committee will hold hearings to lay out the realities of our health care system, and I am committed to working with anyone who is serious about addressing these issues,” Johnson said in a statement that appeared to extend and olive branch to Democrats. “Americans deserve far better than their elected officials have delivered to this point.”

GOP Speaker Paul D. Ryan of Wisconsin reacted to the party’s failed Senate vote by putting the health care onus on the shoulders of his Senate colleagues, urging them to “continue working toward a real solution that keeps our promise.” The House, he said Friday, having passed a health overhaul measure, will move on to issues like taxes.

But there is no guarantee Senate Republicans and Democrats, long ideologically divided on the details of health care, can find enough common ground to craft a bill — or that Ryan would bring it to a vote.

“I can’t speculate about a bill that doesn’t exist,” a Ryan aide said Friday when asked if the speaker put a Senate-passed bipartisan health bill on the floor.

And the White House, the person whose opinion matters most, Trump, appears just fine with both chambers moving on to crafting a sweeping tax overhaul push.

White House officials initially were uncharacteristically quiet following the Senate failure. There was no paper statement issued signaling the president’s preferred next move on an issue that was central to his 2016 campaign message. But Trump weighed in during the wee hours of Friday morning — and endorsed only one path for addressing health care.

“As I said from the beginning, let ObamaCare implode, then deal,” Trump tweeted at 2:25 a.m. Friday. He then ended the tweet with what seemed like a guarantee: “Watch!”

Likely to the chagrin of Republican and Democratic lawmakers, a White House official early Friday afternoon said the president’s tweet represents the administration’s preferred path ahead on health care.

“I’d stick with the tweet,” the White House official told Roll Call, adding a more nuanced description could be coming at some point. (One had not been provided by the time this article was published, however.)

About an hour later, Trump doubled down on his call during remarks in New York state.

“I said from the beginning, ‘Let Obamacare implode and then do it.’ I turned out to be right,” Trump said.

Trump may find some allies on Capitol Hill on the path to a possible implosion.

“I believe it may take Obamacare’s collapse before the parties are willing to work together in a bipartisan manner. The collapse and replace of Obamacare may prove to be the most effective path forward,” Sen. Lindsey Graham, R-S.C., said in May. On Thursday evening, Graham reiterated that stance, saying he would rather “get out of the way” and let the 2010 law fail rather than pass a flawed GOP replacement.

Over an hour after Trump said he was “right” about his implode-and-repair idea, the White House official sent an emailed statement saying the administration “will continue to fight to repeal and replace the Obamacare disaster and to ensure all Americans have access to affordable healthcare, making good on an unwavering promise to the American people.”

“President Trump and his administration will not rest until he can sign a bill that fulfills the shared promise to repeal and replace Obamacare,” the official added after Trump spoke.

That statement, notably, applies to the implode-and-repair scenario of which the president is so fond.

Pitching a scenario under which GOP lawmakers and the White House would stand by and let the 2010 law to continue sputtering — forcing Democrats to beg him to cut a deal to fix it — has been a steady drumbeat for Trump. And, just like early Friday morning, the president always brings it up without being prompted — suggesting that has been his Plan A even as Senate Republican leaders struggled to find one of their own.

For months, and especially since the Senate took up the health overhaul baton in early May, Trump has bounced from one preferred approach to another. And after McCain sent ripple waves across the political world, the president again pitched allowing Obama’s law to, as he often puts it, “fail.”

The president has more than one way to nudge Obama’s law toward failure: Trump could opt to stop paying subsidies to insurance companies; he can order agencies to cease enforcing its requirement for most Americans to obtain health insurance; and he could undermine its markets by stopping all federally financed advertising urging folks to enroll under the law.

But lawmakers, at least before the smoke cleared and the sun rose Friday morning, seemed willing to try a new approach. The first real action may come in connection with the looming reauthorization of the children’s health insurance program.

While many Republicans were not in a mood to discuss next steps on health care policy as they left the Capitol in the middle of the night, Sen. Bill Cassidy of Louisiana was an exception.

Cassidy spoke to reporters outside the Capitol at about 2:30 a.m. Friday, and with Democratic senators and other supporters of the 2010 health law cheering across the lawn, he was already talking about the CHIP legislation as a vehicle for interim changes.

“Insurers will continue to leave markets. People will continue to get quotes they cannot afford, and as folks celebrate in the background, they will be bitter because they will feel like they’ve lost an opportunity for something better,” Cassidy said. “Procedurally, CHIP reauthorization will come up, so perhaps there’s some things that can be done”

https://www.medpagetoday.com/Washington-Watch/repeal-and-replace/66962?xid=nl_mpt_DHE_2017-07-29&eun=g885344d0r&pos=0

Following Republicans’ many attempts to kill the Affordable Care Act this week, culminating in last night’s surprising failure of a “skinny” repeal bill, MedPage Today asked physicians outside the Beltway how they and their patients have been reacting to the drama.

“I think people sort of feel that the whole system is just an angry mess,” said Fred N. Pelzman, MD, of Weill Cornell Internal Medicine Associates in New York City, and weekly blogger for MedPage Today.

In Manhattan, he sees patients of all kinds.

Throughout this process of “dredging up” different repeal bills, instead of patients being relieved that one or another didn’t pass, “there’s a lot of throwing up their hands,” he told MedPage Today in a phone call.

Even those patient who don’t like the Affordable Care Act felt this wasn’t a good process, Pelzman added.

For his own perspective, Pelzman believes that the ACA was a good start but the country should move towards Medicare-for-all (or “god forbid, socialized medicine,” he joked), but he acknowledged that it may not be realistic right now.

“My hope for the future of the healthcare system in this country is that we figure out what that baseline of access and preventive and chronic care that every member of society should have is, and then if people want some platinum policy and want to pay more for this or that, I think the private insurers would be more than happy to provide that.”

“This country needs a safety net that is a little less exclusive … You should be able to get the care you need and if you want to see the world’s greatest heart surgeon, you figure that out.”

“Why should someone who has a child with leukemia … worry that they’re going to have to give up food or their house in order to get their child treatment?” he asked.

“When you hear people like [Sen. John] McCain standing up and saying it’s time to stop making it all what the Democrats want or what the Republicans want, it’s got to be what the people who sent us to Washington want, I think that’s the right message.”

Self-Described Conservative

Daniel Edney, MD, an internist in Vicksburg, Miss., who characterizes his political views as “left of the Tea Party but to the right of most moderates in Washington,” said he isn’t against repealing the ACA as long it can be replaced with something better.

“In the absence of seeing something better, I personally am in favor of fixing what we have,” he said.

He was disappointed that Mississippi’s governor chose not to expand Medicaid.

“If any state in the union needed Medicaid expansion it was Mississippi,” Edney said, adding that it was “absolutely foolish” to give up $2 billion in funding over a political statement.

However, the governor did say he would accept funding through a block grant, an idea that Edney is not opposed to. “It’s not about ideologies, it’s about doing the right thing to help our folks,” he said.

The ideal is “to make healthcare decisions as local as possible,” Edney said.

He’s not hopeful about the prospects of a bipartisan agreement. However, “currently the leadership in Mississippi has a good relationship with the administration,” he said. “Maybe things will improve for us whether there’s a repeal and replace or not.”

Single-Payer Advocate

“People have healthcare and they need healthcare. To take it away from them, that’s just cruel,” said Pamella Gronemeyer, MD, of SEMC Pathology in Highland, Ill., and co-president of her state’s chapter of Physicians for a National Health Program.

Gronemeyer said she fell asleep watching the debate last night but woke up on time to catch the vote.

“I was glad that John McCain voted no and killed it,” she said. “The majority of people I know supported the ACA and did not want it to be repealed.”

“I realize it was a ‘skinny repeal’ but once you get rid of those mandates, it will help break the system,” Gronemeyer added.

The biggest concern Gronemeyer had with repeal was its impact on the critical access hospitals in her state.

“Without the ACA those hospitals are going to close and the rural areas are going to suffer. It’s going to take people an hour or an hour-and-a-half to get to the hospital,” she said.

She also worried about repeal’s impact on Medicaid, noting that southern Illinois has been struggling economically and many people now rely on Medicaid.

Looking ahead, Gronemeyer said, “I’d like to go to single payer … but they keep telling me its not going to happen.”

So, she’s prepared to compromise for the moment.

“We need to fix the ACA. We need to make the markets more competitive, make the premium more affordable” and ensure that deductibles are within reach.

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.