The Health 202: How McConnell could solve his health-care Rubik’s cube

THE PROGNOSIS

Many more turns are needed on the Rubik’s Cube for Senate Majority Leader Mitch McConnell to reach 50 votes for his health-care bill overhauling the Affordable Care Act. More senators have been expressing serious concerns in the final days before they return to Washington for three weeks of what will likely be intense negotiations around the Better Care Reconciliation Act – a bill that contains deep cuts to Medicaid, repeals the ACA’s taxes and many of its mandates and reshapes its subsidies.

Yesterday, Tennessee Sen. Bob Corker (R) said he wants the legislation to provide people with more generous subsidies. On Wednesday, Sen. John Hoeven (R) of North Dakota told constituents he doesn’t support the bill as it currently stands, becoming the tenth Republican senator opposing the measure.

McConnell is watching all of this with trepidation. He warned yesterday that if his members won’t fall in line, he will work with Senate Democrats to fix the Obamacare marketplaces in which some customers will have one or no plan options next year.

“If my side is unable to agree on an adequate replacement, then some kind of action with regard to the private health insurance market must occur,” McConnell said at a Rotary Club event in southern Kentucky, The Post’s Juliet Eilperin and Amy Goldstein report.

McConnell compared his task to working a Rubik’s Cube, the puzzle popularized in the 1980s, at a Thursday event: “I’m in the position of a guy with a Rubik’s Cube, trying to twist the dial in such a way to get at least 50 members of my conference who can agree to a version of repealing and replacing,” he said.

It’s easy to see how the whole effort could crumble (Politico reports that no vote is expected next week and that the goal is now voting in two weeks). But it’s also possible to see how McConnell could hold enough senators together to get his bill over the finish line. McConnell’s team is considering a half-dozen revisions to the bill – a few appealing to conservatives and a few appealing to moderates. Here are some possible changes lobbyists and aides say are being considered behind the scenes:

FOR THE CONSERVATIVES:

1. Lift all the Obamacare regulations from insurers as long as they sell one plan that covers extensive benefits for everyone, as required by the ACA.

Conservative lawmakers and groups have parked on this idea over the last week. It appeals to them because it could lower premiums for people who are generally healthy and don’t need extensive coverage — and simply because it rolls back more of Obamacare. Sen. Mike Lee (R) of Utah, a close ally of Sen. Ted Cruz (R-Tex.), has told leadership he won’t vote for the Senate bill unless it includes the Cruz amendment, his office said.

“The Cruz amendment is our top priority,” Lee spokesman Conn Carroll told The Health 202.

The amendment pushed by Cruz would essentially split the individual market into two parts: Healthy people would tend to buy cheaper, non-ACA-compliant plans, while sick people would buy the ACA-compliant plans.

Because the sick people would be grouped together in one risk pool, premiums for them would skyrocket. Subsidies would protect those earning less than 350 percent of the federal poverty level, but those earning more could get priced out of the marketplaces.

Conservative groups including Club for Growth and FreedomWorks started cheerleading for the Cruz amendment this week, too. FreedomWorks President Adam Brandon said he’d rather Congress just repealed all of the ACA, but said the Senate should add in the Cruz amendment at the very least. Club for Growth President David McIntosh said the Senate bill should allow a full opt-out from the ACA regulations “at a bare minimum.”

2. Expand the use of tax-free health savings accounts, allowing people to use them not just for deductibles and cost-sharing but for monthly premiums as well.

This is a much smaller-bore idea than the Cruz amendment, but it’s still something that appeals to Republicans who have chafed at new restrictions the ACA put on health-savings accounts.

FOR THE MODERATES:

1. Decline to repeal one big ACA tax. Projected by the Congressional Budget Office to raise a whopping $172.2 billion over the next decade, the net investment tax collects a 3.8 percent levy on a couple’s investment income above $250,000.

McConnell could gain two things if he retains the tax. Democrats would lose their effective attack line that Republicans are lowering taxes for the rich (the top one percent of earners pay 90 percent of it). And it could help pay for more generous subsidies or fewer Medicaid cuts.

Even the most conservative members of Congress have expressed a surprising openness to keeping the tax if they get their other demands. Sen. Ron Johnson (R) of Wisconsin has said he could live with keeping it. House Freedom Caucus Chairman Mark Meadows (R-N.C.) told my colleague Mike DeBonis last month that it wouldn’t be a dealbreaker. 

Lee would accept keeping the tax if he gets his ask for the Cruz amendment, his spokesman said.

Keeping any of the ACA taxes would anger groups like Club for Growth and Americans for Tax Reform. ATR President Grover Norquist said he would urge a vote against any bill that retains the net investment tax. Cutting capital gains taxes is the best pathway to job creation, and that, in turn, would cause more Americans to gain employer-sponsored coverage, he said.

“It is an idea — it’s a stupid idea,” Norquist told The Health 202.

The opposition might not be enough to sink the notion. “Those groups are all friends of ours, and friends don’t agree on everything,” Carroll said.

2. Add in more funding for opioid abuse prevention.

The Senate measure currently provides just $2 billion for states to respond to the opioid abuse epidemic. GOP Sens. Rob Portman of Ohio and Shelley Moore Capito of West Virginia, who have made it their pet issue, have been reportedly told the revised bill will provide their original request of $45 billion for opioid response.

3. Roll back some of the bill’s roughly $800 billion in federal Medicaid cuts.

The Senate bill’s dramatic cuts to Medicaid – which would result in a quarter less federal spending on the program by 2026 – is the biggest concern moderate senators have cited with the bill. McConnell could address their concerns in a number of ways. He could chain federal Medicaid spending it to a faster-growing index. Or he could phase out Medicaid expansion even more slowly, extending its extra federal payments beyond even 2024.

AHH: A U.S. hospital has offered to admit Britain Charlie Gard, the terminally ill 11-month old to be removed from life support against the wishes of his parents per court order, The Post’s Lindsey Bever and Alex Horton reportNew York Presbyterian Hospital and Columbia University Irving Medical Center agreed to admit and evaluate Charlie “provided that arrangements are made to safely transfer him to our facility, legal hurdles are cleared, and we receive emergency approval from the FDA for an experimental treatment as appropriate,” the hospital said in a statement Thursday. The hospital also offered to ship experimental medication to the London hospital where Charlie is being treated as a second option.

Charlie, who has a rare genetic condition, captured worldwide attention when European courts decided the boy should be removed from life support against the wishes of his parents. Both Pope Francis and Trump have offered words of support, the president tweeting earlier this week that the United States “would be delighted” to help Charlie. 

Antiabortion groups including Susan B. Anthony List, Concerned Women for America and March for Life have rallied around the cause, holding a news conference yesterday, starting an online petition and creating social media hashtags to pressure the British hospital housing Charlie to release the infant to his parents.

“The idea that a government may override and block parents’ decisions about the care for a child is horrifying,” the groups said in a joint statement. “This is their child and they want to use money they have raised from private donors around the world to provide him access to a treatment option that has had some success with a related condition. It is chilling that the UK court is allowing the London hospital to deny the family this option.”

OOF: Even as Democrats rally opposition to Republicans’ deeply unpopular attempt to repeal parts of the ACA, they’re facing a political challenge of their own: increasing pressure from their liberal base to embrace universal, government-funded health-care coverage, The Post’s David Weigel reports.

Sen. Bernie Sanders (I-Vt.), perhaps the country’s most prominent proponent of universal coverage, is getting ready to introduce a new bill toward that end. Two potential 2020 presidential candidates — Sens. Elizabeth Warren (D-Mass.) and Kirsten Gillibrand (D-N.Y.) — each said last week that the party needed to get behind “Medicare for all.”

Republicans have noticed — and have begun to attack,” Dave writes. “Facing a widespread voter backlash over the House and Senate repeal bills, they’re trying to make universal coverage a political anchor for Democrats by asking whether they can seriously defend trillions of dollars in new taxes and spending.”

Yet the idea of government-provided health insurance is gaining in popularity. “Medicare for all” polls better than either party’s current health-care positions,” Dave writes. “Last month, a new study from Pew Research found 60 percent of all voters agreeing that it was ‘the federal government’s responsibility to make sure Americans have health coverage.’ Thirty-three percent of all voters favored a single government insurance system; among Democrats, the number rose to 52 percent, having grown every year since the ACA’s passage.”

Here’s a snapshot of growing support for universal health coverage : Democratic Sen. Claire McCaskill of Missouri informally polled her constituents about health care during a series of town halls this week, Politico reported. Two people out of five dozen raised their hands when she asked whether they support the GOP health-care bill. But about a dozen hands shot up when McCaskill asked attendees whether the U.S. should have a single-payer system.

McCaskill told the crowd that she was “not there yet” on single payer because of the costs, but added that she’d support a government “public option” plan. “I certainly wish we would have provided the ‘public option’ with the Affordable Care Act,” she said. “I was against it at the time. So I think I made a mistake on that.”

OUCH: No one thought Republicans would have the chance to work on health care this year under a President Hillary Clinton, Sen. Patrick J. Toomey (R-Pa.) suggested as a reason for why the GOP bill might be missing the mark. “Look, I didn’t expect Donald Trump to win, I think most of my colleagues didn’t, so we didn’t expect to be in this situation,” Toomey said during a televised town hall on Wednesday night.

His analysis was pretty much right on, my colleague Paul Kane writes.

“Every important Republican leader expected Democrat Hillary Clinton to win, and that left Republicans confused and paralyzed about how to proceed when she didn’t,” Paul writes. “That in turn led to a rushed initial decision….during the presidential transition, to push for a full repeal of the 2010 health law and then set up a two- to three-year window in which Republicans would pass bills to replace it…They have themselves to blame for not being ready from the outset to handle the health-care issue and others. Now, we know they admit it.”

–Cruz made some ripples at a town hall meeting last night, where he said he agrees with President Trump: If Republican senators are unable to pass a bill to repeal and replace key parts of the ACA, the Senate should vote on a narrower bill to simply repeal the law and work on a replacement later, my colleague Sean Sullivan reported on the scene.

Cruz said Trump was “absolutely right,” per Texas Tribune’s Patrick Svitek: 

“If we cannot bring the conference together and agree on repeal legislation, then I think President Trump’s absolutely right that we should pass a clean repeal,” Cruz told reporters, adding that such a repeal should be delayed “either a year or two years” to give lawmakers time to work on a replacement.

“Cruz, who has advocated for a ‘clean repeal’ in the past, said he still believes the Senate can pass some version of the sweeping bill to repeal and replace the ACA that GOP leaders have been struggling to build support for in recent weeks,” Sean writes. “I believe we can get to yes,” Cruz said. “I don’t know if we will.”

The Texas Tribune reporter tweeted Cruz’s response, when asked if he thought he’d be blamed for the bill’s potential failure:

–Earlier in the day Thursday, my colleague Dave Weigel staked out Sen. Jerry Moran’s (R-Kan.) first town hall meeting since coming out against the GOP health-care plan. Moran wanted to make himself clear — or not. “He didn’t want legislation jammed through on a party-line vote, but he would ‘not necessarily’ vote against it. He’d met people who ‘tell me they are better off’ because the Affordable Care Act was passed, but he knew plenty of people were hurting, too,” Dave writes.

“It’s worthy of a national debate that includes legislative hearings,” Moran said after the 90-minute event that brought 150 people to a town of 277. “It needs to be less politics and more policy.”

“Moran, the only Republican senator holding unscreened town halls on health care this week, revealed just how much his party is struggling to pass a bill — and even how to talk about it,” Dave writes. “The people who crowded in and around Palco’s community center aimed to prove that there was no demand for a repeal of the ACA, even in the reddest parts of a deep red state.”

Moran also got questions about defunding Planned Parenthood (part of the Senate health-care bill) and single-payer, Dave noted:

Weigel tweeted that Moran was asked about a single-payer system, and a constituent attracted “huge applause” for asking about “Medicare for all.” 

The Wall Street Journal’s Michelle Hackman had a thread of interesting takeaways from the event. She noted that Moran avoided the term “repeal” and didn’t take a chance to criticize Obamacare:

 

A few more interesting health-care reads:

Coming Up

  • Sen. Bernie Sanders (I-Vt.) is planning to hold “Care Not Cut” rallies in Kentucky and West Virginia on Sunday. 
  • The Senate returns from its July Fourth recess on Monday. The House returns on Tuesday.
  • The Bipartisan Policy Center is holding an event on solutions to long-term care financing on July 11. 
  • The Hill is hosting an event on “The Cost of Caring: Family Caregivers and Tax Reform,” featuring Sen. Tammy Baldwin (D-Wis.), Sen. Joni Ernst (R-Iowa), Rep. Dan Donovan (R-N.Y.) and Rep. Michelle Lujan Grisham (D-N.M.) on July 13.

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