See No Evil Trumpcare

Senate Republicans are pretending the AHCA simply doesn’t exist.

U.S. Speaker of the House Rep. Paul Ryan (R-WI) (L) and Senate Majority Leader Sen. Mitch McConnell (R-KY) (R)
Speaker of the House Rep. Paul Ryan and Senate Majority Leader Sen. Mitch McConnell in front of the West Wing of the White House on Feb. 27 in Washington.

Alex Wong/Getty Images

Senate Republicans have figured out how to treat the American Health Care Act. To them the House health care bill is a piece of legislation not just passed by another chamber, but in another time, on another planet, with no relevance to any ongoing legislative activity in their own chamber on Earth 1 in the year 2017. For a group that waited months for the House to pass its legislation before lifting a finger to begin drafting their own, Senate Republicans are acting almost perplexed as to why any reporter would dare ask them about the AHCA’s highly anticipated Congressional Budget Office analysis released Wednesday.

“That’s yesterday news,” Arizona Sen. Jeff Flake told me on Thursday when I asked what his policy takeaways were from the CBO score. (It’s true, Thursday does come after Wednesday.) Louisiana Sen. Bill Cassidy, typically one of the chamber’s most insightful health care commentators, also described it as “yesterday’s news.” Nebraska Sen. Deb Fischer responded to several of my questions by noting that the Senate was writing its own bill.

“I’m not going to be focusing on someone else’s bill,” Pennsylvania Sen. Pat Toomey said when asked about the score.

Part of the reason the Senate chose to write a new bill rather than amend the AHCA was to avoid answering such questions at this moment. The CBO score of the late-stage changes to the bill revealed more or less what everyone knew it would reveal: It worsens protections for those with pre-existing conditions, rather than adding the “multiple layers of protection” that House Speaker Paul Ryan had promised. It showed that the MacArthur amendment—which clinched the Freedom Caucus’ approval of the bill—would erode insurance protections in waiver states for patients with pre-existing conditions and that the Upton amendment—which clinched enough moderate support to get the bill over the finish line—would provide not nearly enough money as a backup for those priced out of insurance markets. The CBO estimated that 1 in 6 Americans would live in states waiving both community rating and essential health benefit coverage requirements, offering healthy patients lower premiums for less comprehensive plans and “extremely high premiums” for the sick.* The Upton amendment’s $8 billion in funds for five years—slotted in for waiver states to protect their sicker populations—“would not be sufficient to substantially reduce the large increases in premiums for high-cost enrollees,” the CBO found.

But that’s all in the House bill, as Senate Republicans said over and over on Thursday. Which raises a question for these demure senators, though: What would their health bill do so differently, specifically on the pre-existing condition front?

There are two broad options for fixing the problem posed by the MacArthur amendment’s waivers and the nasty trade-offs—analyzed and confirmed to the best of CBO’s ability—implicit in this kind of health insurance deregulation. You can spend more money on sick people, or you can just abandon this approach altogether. Since most senators I spoke to Thursday mentioned the need to retain “flexibility” for states—permission for states to wind down the Affordable Care Act regulations in question—it sounds like it will have to be the former.

“There has to be some kind of federal backstop for pre-existing conditions and chronic care,” North Dakota Sen. John Hoeven said. I asked him if he thinks that means more money.

“Yeah, it does.”

Utah Sen. Orrin Hatch was one of the few senators who would admit that the CBO score caused “a lot of concern” among Republicans. Shortly thereafter, though, he got back on message, saying “of course that was the House plan, and that’s not going to be the final bill anyway.” Still, Hatch expects that “the waivers probably will be part of the final bill,” which, again, likely means more money.

“That’s gonna be the argument,” he said.

It is theoretically possible to come up with a precise dollar amount—substantially higher than $8 billion, mind you—that could cover those with expensive medical conditions in high-risk pools who’ve been priced out of insurance in states that received waivers. As Hoeven said, that number could be determined in consultation with the insurance industry and actuaries.

Adding tens or hundreds of billions of dollars of spending to the bill, though, comes with a procedural hiccup. A held-over point of order in the 2016 budget resolution requires the Senate bill to save at least as much as the $119 billion that the CBO projected the House bill would save. Where would new funds for sicker people in waiver states come from to make up for this gap? (Never mind any additional lost savings that might occur if the Senate softens the House bill’s harsh Medicaid cuts.) The money has to come from somewhere, but reviving, say, Obamacare’s net investment tax or any of its other large revenue raisers does not seem to jibe with the party’s current ideological goals.

Still, the work must go on. The Senate health care working group will begin drafting legislative language over next week’s recess, Wisconsin Sen. Ron Johnson told reporters Thursday. The group, he acknowledges, hasn’t yet achieved consensus on how exactly to do that. Maybe they’ve got something truly original up their sleeves that’s a complete break from the House vision. There’s been some talk recently of automatically enrolling people into health insurance as a means of broadening risk pools (and thus lowering premiums), but conservatives probably never would go for such a “mandate” upon “individuals.”

Otherwise, there’s no indication for how the framework of the Senate bill would differ meaningfully from that of the House bill. The refundable tax credits for people on the individual market will likely be reworked to align more with income rather than age. The blow to Medicaid could be softened. More money could be offered to protect those with pre-existing conditions. It may help Senate Republicans politically—specifically when reporters are nagging them about the horrors in the House bill as described by the CBO—to act as though they’re making a fresh start. The AHCA, though, is still the foundation on which this reform effort is built, and far from yesterday’s news.

*Correction, May 26, 2017: This piece originally misstated that the CBO estimated 1 in 6 states would waive both community rating and essential health benefits. The CBO estimated that 1 in 6 Americans would live in such states. (Return.)