How Insane Could This Get?

At long last, the Senate is poised to begin voting today on a measure to repeal and/or alter portions of the Affordable Care Act.

Much remains in flux regarding process and the substance of what will be voted on.   According to multiple media sources today, Senate leaders latest strategy is to hold a vote on a narrower piece of legislation than those circulated in recent weeks.

The substance of such a measure—if indeed, it exists and is submitted for a vote—is unclear as of this posting.  But it reportedly could contain just a repeal of the ACA’s individual and employer mandates and a few of the law’s taxes, such as the one on medical device companies.

This narrow, or “skinny,” bill would not have any provisions pertaining to Medicaid.

The idea, apparently, is to pass this initial piece of the puzzle—to get things going—and then to take up the larger and more controversial issues that have so deeply divided the Republican caucus.

According to the Huffington Post, House and Senate leaders would then try to negotiate a version of the more comprehensive legislation in both chambers that Republicans could rally around.

That would seem still to be a tall order, especially if they are still trying to get it all done before the August recess, which begins August 11.  Of course, that’s subject to change as well.

And there’s not yet any certainty that initial votes would allow this “skinny” bill process to proceed.  Some Republican lawmakers might balk out of concern that no replacement for the mandates and larger bill, for example, would ever be forthcoming.  That would then compel a vote to repeal the initial repeal bill since that bill would likely lead to a rush to the exits by insurers now serving the exchange markets.

CBO has estimated that repealing the individual mandate while leaving the rest of the ACA’s regulations in place would result in 14 to 15 million more uninsured and premium hikes of 20 percent within a few years.

There’s broad consensus that John McCain’s return to the Senate today adds significant impetus to Republican efforts—in terms of sentiment and possibly some outright political opportunism leveraging his dire diagnosis to spur action.

As Axios’ David Nather opined this morning: “How insane could all this get? Completely, wildly, utterly, spectacularly insane.”

Further spinning our heads in the last few days, Democratic leadership has begun to talk openly about submitting and pushing a “Medicare for All” bill this year and in 2018 if the Senate effort fails.

THCB’s editor asked me to write this quick synopsis of where things apparently stand today (July 25), and to get the ball rolling on comments and updates over the coming days.   All thoughts welcome as this historic process begins.


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13 replies »

  1. Of course not. I was pointing out to you that there was a lot more involved in pricing than just the act of centralizing healthcare and I gave just one small example. I am basing a large part of the problems of our system on a lack of liquidity constraint that one sees with third party payer.

    When you had your surgery done out of the country you did so because you were responsible for the bill.

  2. Skinny repeal fails with Murkowski, Collins and McCain breaking ranks to vote against GOP leadership.

    It’s time to face facts – ACA repeal is over, at least for now. With midterm campaigns looming, Congressional Republicans need to shift gears and actually pass legislation that speak to middle class voters. Expect lots of talk about tax cuts in the coming weeks and a quick desire to move on from healthcare.

  3. “There is some centraliztion in our healthcare system and that leads to some patients automatically given gym memberships in part paid for by the American taxpayer.”

    You’re basing the failure of the system on gym memberships? Really?

  4. Since the prices of all these different nations vary considerably there is a lot more involved in pricing than just the act of centralizing healthcare.

    I wonder if gym memberships are paid for by government health insurance in Canada or France. There is some centraliztion in our healthcare system and that leads to some patients automatically given gym memberships in part paid for by the American taxpayer.

  5. But Steve, POTUS says the Dems are being obstructionists. They refused to attend even one of the many hearings that the GOP has held on their replace bills……. Ok, that was too much fun. Really don’t see the Dems doing anything that would look like they were bailing out the GOP.


  6. Another vote will occur today, on the bill to “repeal and delay.” It will fail, as did last night’s Better Care Reconciliation Act, version 2.5.

    After that, it looks as is the “skinny” bill will be introduced, possibly as early as tomorrow.

    This is not a bill that any senator has yet seen! And it’s unclear whether the Republican moderate camp or conservative camp will support it.

    In keeping with the bizarre nature of this process, the contents of the skinny repeal bill do not seem to matter. They’ll be symbolic—allowing some Republicans to say they voted to repeal the individual and employer mandates, for example.

    Rather, the skinny repeal bill is a vehicle and tactic. If it musters 51 votes, its passage would lead to a conference committee with the House. Negotiations could then continue in both chambers, possibly past the August 11 recess and into September, in search of a larger-scope bill that could garner enough R support to pass.

    McCain’s passionate plea yesterday to his colleagues to stop all this nonsense and reach across the aisle on big issues like health care is unlikely to change anything, particularly since McCain ended up voting for BCRA hours after he said he would not.

    There’s zero indication that Rs are reaching out to D’s—yet. Notably, though, Ds can submit amendments and it’s feasible amendments from either Rs or Ds could garner D support. In particular, any move to add funding for CSR payments and reinsurance—both of which were in BCRA and the House bill—into the skinny bill could draw D votes in favor.

    Julie Rovner has today’s best explanation of the legislative process, at knn.org. Here’s the link: http://khn.org/news/who-knew-senate-health-bill-debate-could-be-so-complicated/

    Relevant to the skinny bill, see Sherry Glied and Adlan Jackson’s “Why There’s No Substitute for the Individual Mandate” at the Commonwealth Fund site. It’s a reminder to R lawmakers of why they have so far failed to find an alternative to the mandate, and why the CBO keeps scoring its repeal so severely.

    From the AMA’s statement this morning: “Eliminating the mandate to obtain coverage only exacerbates the affordability problem that critics say they want to address. Instead, it leads to adverse selection that would increase premiums and destabilize the individual market…..We again urge the Senate to engage in a bipartisan process – through regular order – to address the shortcomings of the Affordable Care Act and achieve the goal of providing access to quality, affordable health care coverage to more Americans.”

  7. “Do we really want a more centralized, onerous, bureaucratic healthcare industry governed by institutional co-dependency?”

    What would that look like – Canada, Germany, France, with half the cost?

  8. Calendar No. 120, H.R. 1628, “The American Health Care Act” is the bill now voted on “Motion to Proceed” for Senate debate (via 51-50 vote, Pence tie-breaker). 132 pages at this point (in my PDF download). The word “repeal” occurs 42 times. Salient because it’s a “budget reconciliation” bill not subject to 60-vote supermajority. Only speaks to rescinding spending authority provisions granted the PPACA pertaining to THIS federal fiscal year (that’s what “budget reconciliation” means).

    The phrase “the Secretary” appears 36 times (goes to HHS “regulatory discretion”). “Amend,” 100 times, “amended” specifically 67 times. THAT stuff has you scurrying over to the other laws cited for amendment.

    Notable for its utter lack of specifics, beyond cutting funding for ACA provisions. Nil amount of “Replace” language.

    Will have to watch closely for ‘bait and switch” updates.

  9. I guess they cannot not vote for this bill because all the Pubs voted for the same bill in 2015 and there is nothing in it other than opening it up for discussion.

  10. Pen-in-hand-sitting-waiting-in-the-Oval-Office Trump in particular just wants a bill to sign. He will never read the first word of it; he simply doesn’t care, all he wants is to be able to go on to his next red state Trumpkin MAGA eternal campaign rally and crassly brag about his “Great Win on Health Care.” There will be PLENTY of time later to blame everyone else for the inevitable subsequent Custerfluck.

  11. For the ACA 2010, we had over-whelm and conquer. Now instead, we have divide and conquer. Neither strategy has had or will have any effect on the cost and quality problems of our nation’s healthcare. Do we really want a more centralized, onerous, bureaucratic healthcare industry governed by institutional co-dependency?

  12. As of late this afternoon (July 25) it appears that a “skinny” bill may be a back-up after fatter (more comprehensive) repeal and replace or repeal and delay bills fail.

  13. Thoughts? The GOP just wants to pass something since they promised they would. They risk a lot of negative feedback from voters if they do not. I think it likely they will pass something. I think that they will either pass a simple repeal bill, then hope they can do something later, or pass a bill with big Medicaid cuts. If there are any issues on which conservatives are pretty consistent, it is cutting taxes and cutting spending on the poor. If they were really serious about passing a good bill they would have hearings and solicit opinions from a lot o other people. They would be out trying to sell the bill. Don’t see any of that happening.