Caitlin Owens
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Some parts of GOP health bill violate Senate rules

Andrew Harnik / AP

The Senate parliamentarian ruled Friday that some parts of the Senate health care bill do not comply with budget rules, meaning that if they're included in the bill, they'll need 60 votes to pass. (They won't get 60 votes.)

The biggest provisions that will have to come out if the Senate follows past precedent: Planned Parenthood defunding, abortion funding restrictions, and funding for insurer cost-sharing payments. However, one of the most controversial amendments of the bill, Sen. Ted Cruz's Consumer Freedom Act, wasn't included in her ruling, as it only addressed an earlier version of the bill that didn't include it.

The big things she said don't comply:

  • The provision barring Planned Parenthood from receiving Medicaid funding for a year
  • The language preventing premium tax credits from being used for plans that cover abortion
  • Funding for insurer subsidies, known as cost-sharing reduction subsidies
  • The six-month waiting period for the individual market for people who haven't maintained continuous coverage
What's still under review:
  • Enhanced waivers for some Affordable Care Act regulations
  • A provision allowing small businesses to establish association health plans
  • The provision allowing insurers to charge older people more than younger people compared to the ACA
  • The option for states to receive a block grant instead of a per-person funding cap
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Republicans' many health care flip-flops

Lazaro Gamio / Axios

The best way to summarize the Senate health care effort right now is that no one has any idea what's going on. They might vote on a replacement bill, or maybe a tweaked version of that replacement bill, or maybe the same repeal bill they voted on in 2015 (which wipes out much of the Affordable Care Act without replacing it).

But while the confusion has escalated this week, it's not new. Lawmakers have made a lot of contradictory statements throughout the process, sometimes asking for entirely different things at various points in this hectic eight-month journey. We've compiled some of the biggest about-faces.

Sen. Rand Paul

  • In January: "If Congress fails to vote on a replacement at the same time as repeal, the repealers risk assuming the blame for the continued unraveling of Obamacare."
  • On Tuesday: "It's a great step forward that we plan to take up the 2015 repeal bill instead."
Sen. Tom Cotton
  • In January: "When we repeal Obamacare, we need to have that solution in place moving forward … I don't think we can just repeal Obamacare and say we'll get the answer two years from now."
  • This week, on the 2015 repeal bill: "49 senators should be voting for it since they did 18 months ago," he told me.
Sen. Dean Heller
  • Last month: "It's going to be very difficult to get me to a yes," he said, citing concerns about what phasing out Medicaid expansion would do to the state budget and saying that the bill didn't do anything to lower premiums.
  • Wednesday night: "I'm not saying I'm a no vote but I'm just saying, I want to have all the information that I can have and continue to gather this information to the point that I can actually make a decision." He wouldn't say what he wanted in terms of Medicaid cuts or premiums.
Sen. Bill Cassidy
  • In May: Created what he called the "Jimmy Kimmel test," which measures whether a "child born with a congenital heart disease [would] be able to get everything she or he would need in that first year of life...even if they go over a certain amount."
  • This month, struck a deal with Sen. Ted Cruz that would essentially create separate insurance markets for sick and healthy people. Some experts say this could make coverage unaffordable for people with pre-existing conditions.
Sen. Mike Lee
  • In June: "The first draft of the bill included hundreds of billions of dollars in tax cuts for the affluent..."
  • This week, after Republicans agreed not to repeal the ACA's tax on net investment income for wealthy people: "In addition to not repealing all of the Obamacare taxes, it doesn't go far enough in lowering premiums for middle class families."
And then there's the moderates:
  • To be fair, the vote on the 2015 bill was 18 months ago. But Sens. Lisa Murkowski, Shelley Moore Capito, and Rob Portman all voted for the repeal-only bill then and are no longer supportive of that strategy.
  • Sources included John Hoeven among those who urged Vice President Pence to give them more time to strike a deal, as they were likely to vote no on the 2015 repeal bill. However, his office today said Hoeven would vote in favor of the bill.
  • But also to be fair, it seems reasonable to think they're now convinced a replacement isn't coming.
The most consistent of them all: Sen. Susan Collins. Congrats, senator!

This story has been updated to clarify Hoeven's position on the 2015 repeal bill.

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Dean Heller is keeping his options open on health care

AP Photo/Pablo Martinez Monsivais

Sen. Dean Heller has been tight-lipped on the Senate health care plan ever since his fiery joint press conference with Gov. Brian Sandoval last month, following the release of the first version of the bill. But I finally caught up with him last night after the late-night GOP meeting in the Capitol, and he gave me several minutes of his time to discuss where he now stands.

Here's some excerpts from our conversation. In short, he's not drawing any firm lines in the sand and remains open to striking a deal.

So you came out in your press conference a few weeks ago – you were pretty clear about what the bill didn't do, about which expectations of yours it didn't meet. Can you tell me now where you stand? What are your expectations as of now, and where do you see the movement towards what you're looking for?

"I don't have an answer to that question. I truly don't have an answer to that question, because things are changing so quickly ... And it's not because I'm undecided – all I'm trying to do is get all the information I possibly can before I make a decision."

Is there – with coverage numbers, could any Nevadans lose coverage? Or is there kind of like a threshold that you have set for yourself?

"See, I'm not going to talk about that. Yeah, that's not the discussion I want to have. The discussion I want to have is to see what the options are, so that we can make the best decision and choice for the state of Nevada. And if that's a no vote, that's a no vote. I'm not saying I'm a no vote but I'm just saying, I want to have all the information that I can have and continue to gather this information to the point that I can actually make a decision. I'm not at the point I can make a decision."

Similar question on premiums – if premiums do not decrease, is that something – have you made a hard line –

"That's one of the variables in this process."

So you don't know – say they increase, you don't know if that would kill your vote.

"Well, you know, all the scoring and everything, I want to see it. Read it. I want to understand it. And if I have questions, I want to be able to go to people that can answer those questions."

You sound pretty flexible.

"I hope so. I hope to be. And I think, frankly, that's what I should be doing."

So like a voter from Nevada was coming up to you and said, 'What won't you support?' What would you tell them?

"It just depends on the individual. We'll sit down and talk about what their concerns are, what their problems, then we'll address those specifically."

I know Gov. Sandoval said he doesn't like the 2015 straight repeal bill (he joined a bipartisan group of governors opposing it). Is that a factor in your vote too? The fact that he said he does not like that?

"Everything's a factor. Everything's a factor."

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Senate GOP has only bad options on health care

AP Photo/Andrew Harnik

Senate Republicans reversed course yesterday and plowed ahead with their plan to repeal and replace the Affordable Care Act — ignoring all the experts, actuaries, independent analysts, governors and even voters who say their bill would lead to millions of people losing insurance and make it harder for sick, poor people to obtain coverage.

  • Aides are frustrated and candidly skeptical that a deal is achievable at this point. One senior GOP aide referred to the bill — as well as a straight-repeal bill the caucus is now also considering — as "corpsicles." Another aide said, "It's a terrible idea to make people vote for the 2015 [repeal] bill" and that last night's attempt to revive the replacement bill was a "death rattle."
  • "They can't accept they've been promising something that is undeliverable and a bad idea for seven years," one well-connected former GOP aide told me.
  • Bottom line: Congressional Republicans aren't listening.

They're ignoring health care experts, industry groups, governors from both parties, and voters. Many of them seem to have decided passing something — anything — is better than failure. The irony is that if they succeed, and everyone else was right about the effects of this bill, they'll own the disastrous consequences. Either way, it looks very much like they're about to be forced to go on the record on one of these bad options.

"Governors, industry and policy experts are not really the right experts for the problem at hand. This is no longer about salvaging what is left of the individual market. This about salvaging what's left of the Republican Congress," one health care lobbyist said.

Two bad options: It remains unclear what the Senate is actually going to vote on next week. It might be the latest Senate bill — or a version of it — which restructured some parts of the ACA and dramatically overhauled Medicaid. It might be their 2015 bill, which repealed large parts of the ACA without replacing them. It might be both. If there aren't 50 votes to begin the substantive voting process, it might be neither.

The polls:

  • Earlier this month, the Kaiser Family Foundation found that 61% of Americans viewed the GOP replacement plan unfavorably, with only 28% viewing it favorably.
  • The same poll found that only 26% favored the repeal now, replace later strategy.
  • An AP poll found only 13% of the public favored repealing the ACA without a replacement ready.
Analyses of the replacement plan:
  • 22 million more people would be uninsured by 2026 and 15 million more next year, compared to current law, according to the Congressional Budget Office. Markets would be relatively stable, but in some places, no insurers would participate in the individual market, or would charge very high premiums. Premiums would rise in the short term, then fall; deductibles would rise across the board.
  • On an amendment offered by Sen. Ted Cruz (allowing insurers that offer ACA compliant plans to also offer non-compliant plans) that was included in the most recent version of the bill:
    • "This would allow the new plans to "cherry pick" only healthy people from the existing market making coverage unaffordable for the millions of people who need or want comprehensive coverage," America's Health Insurance Plans and the Blue Cross Blue Shield Association wrote in a joint letter.
    • The American Academy of Actuaries: "Rather than having a single risk pool, in which costs are spread broadly, there would be in effect two risk pools—one for ACA-compliant coverage and one for noncompliant coverage. As a result, average premiums for ACA-compliant coverage could far exceed those of noncompliant coverage, thereby destabilizing the market for compliant coverage."
And on repeal only:
  • Per CBO:
    • 17 million more Americans uninsured next year, 32 million more by 2026
    • Premiums would rise by 25 percent next year, 50 percent by 2020 and 100 percent by 2026.
    • By 2026, about three-quarters of the population would live in places with no insurers participating in the individual market.
  • A bipartisan group of 11 governors: "The Senate should immediately reject efforts to 'repeal' the current system and replace sometime later. This could leave millions of Americans without coverage."
  • Catch-22: McConnell brought this bill up knowing these would be the consequences. But most of the caucus has already voted yes on this bill, so flipping their votes would earn them accusations of playing politics.
  • But, but: It's now apparent congressional Republicans can't coalesce around a replacement plan, unless something changes quickly. So saying you'll vote to repeal now and then will come up with a replacement plan later isn't a strong justification.
Who is happy: Conservative advocacy groups. They're especially pleased with the prospect of straight repeal. It's becoming very apparent that theirs is the loudest voice in the room. "McConnell will always protect his right flank," one former Senate GOP staffer told me.
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After White House flip-flops, health care strategy still in flux

AP Photo/Pablo Martinez Monsivais

President Trump isn't the only White House official sending mixed messages about how the Senate should handle the Affordable Care Act.

Shortly after Trump told Senate Republicans at a lunch meeting today that his preference is to repeal and replace the law at the same time, Paul Teller, a White House legislative affairs aide, sent out an e-mail asking recipients to support a 2015 bill that would only repeal the law, without replacing it.

  • "As soon as this coming Monday the 24th, Congress could move to proceed to the House-passed healthcare bill and replace it with the text of the 2015/2016 Obamacare repeal reconciliation bill, which Congress passed but President Obama vetoed," Teller wrote.
  • "We'd be grateful if you could publicly support the motion to proceed (MTP) to the healthcare bill in the Senate — as well as the 2015 bill itself. As Vice President Pence said this week, 'Inaction is not an option," he wrote. Teller also attached a summary of the 2015 bill, which would repeal most of the ACA and does not include a replacement plan.
  • The e-mail was sent to conservatives on and off the Hill.
  • Of course, regardless of what the final product is, 50 GOP senators would have to vote to begin debate on the bill (even though three have said they won't), which was the first half of Teller's ask. Technically, straight repeal and repeal-and-replace could both get a vote once the debate begins — but only one can be the final product.
  • This afternoon, White House policy chief Marc Short gave an on-camera briefing reiterating the president's support for repealing and replacing the ACA.
Moderate Senate Republicans are also sowing confusion. During a caucus lunch yesterday, they helped persuade the White House that repeal-and-replace is still viable, according to three senior aides:
  • When McConnell announced to senators that the plan was to vote as early as the next morning to begin debate on the bill, most were ready to go ahead and vote. Vice President Mike Pence, who attended the meeting, also came in supporting the repeal-only strategy.
  • But some senators — who voted for straight repeal in 2015 but were expected to oppose it this time — asked for more time, saying they were close to a deal on the Senate's repeal-and-replace bill. These included Sens. Rob Portman and John Hoeven.
  • Three key holdouts — Sens. Susan Collins, Lisa Murkowski and Shelley Moore Capito — didn't join that protest.
  • By the end of the lunch, Pence seemed convinced the Senate bill was still in play.
  • A day later, Trump (and Short) urged the caucus to keep looking for a repeal-and-replace deal.
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Senate Republicans don't know what they're voting on next week

AP Photo/Jacquelyn Martin

It's up in the air what Senate Republicans will vote on next week, following their meeting with President Trump on Wednesday. The goal seems to be to get something passed, regardless of whether it just repeals parts of the Affordable Care Act or tries to replace them.

When asked whether the vote would be on repeal, the latest version of the Senate replacement bill, or some other replacement plan, Finance Committee Chairman Orrin Hatch said, "It could be all of the above, but at least one." He said Trump's message to the caucus was to "unify and get things done."

Why this matters: It can't be overstated how wild it is that Senate Republicans are planning to vote on a massive restructuring of the health insurance system next week, without knowing what it will look like. And though passage of anything seems unlikely, if they do manage to pass a replacement bill, it'll be a patchwork of last-minute compromises on top of a bill that is already massively unpopular and hasn't been thoroughly analyzed. And Republicans will then own whatever happens under their bill.

What we know:

  • The first vote will be a vote to begin debate on the House bill. If that passes, the Senate can vote on amendments, including substitutes to the underlying bill.
  • "The plan is to bring up the 2015 bill, but there was an agreement today to continue talking on some of the issues that our members have," said Sen. John Thune, the third-highest ranking Senate Republican.
  • The 2015 repeal bill already has three defectors. Only two — or one, if Sen. John McCain is still out when the vote happens — are needed to kill it.
  • The most recent version of the Senate replacement bill had four defectors, split among moderates and conservatives. Sens. Shelley Moore Capito and Lisa Murkowski indicated after the bill was shelved that they would have voted against it.
  • There's no reason both senators couldn't vote on both the 2015 bill and the latest replacement plan — if the vote to begin the debate succeeds. But that's a huge "if."
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GOP health care holdouts to meet tonight to work it out

Pablo Martinez Monsivais / AP

All of the Republican senators who oppose the Senate health care bill are meeting tonight to work out their differences — after being told by President Trump this afternoon that they need to work late into the night to get a deal. The holdouts, including moderates and conservatives, are scheduled to meet in Sen. John Barrasso's office at 7:30 pm Eastern with the goal of getting a deal to revive the shelved Affordable Care Act repeal and replacement bill, according to sources with direct knowledge of the discussions.

What Trump said: At the White House lunch today, Trump told all Republican senators that he'd prefer a repeal and replacement plan, but that at a minimum, the Senate needs to at least repeal the ACA to live up to their promises. He signaled that he'd be open to adding money to make it a stronger plan — which one person in the room interpreted to mean that Republicans could add money to the bill's stabilization fund for state insurance markets.

Pressure on the holdouts: Senate Majority Leader Mitch McConnell told the senators that at the very least, they should vote next week for the procedural motion to take up the bill — noting that Republicans have run on ACA repeal in four elections and need to at least start the debate.

How the meeting came together: After Trump suggested it, Vice President Mike Pence walked over to conservative Sen. Mike Lee and moderate Sen. Rob Portman — two of the holdouts against different versions of the repeal bill — and asked them if they'd participate in the meeting. Both agreed. Health and Human Services secretary Tom Price and Centers for Medicare and Medicaid Services administrator Seema Verma are also expected to be there.

Also invited to attend: Sens. Shelley Moore Capito, Ted Cruz, Jerry Moran, Bill Cassidy, Mike Enzi, James Lankford, Ron Johnson, Mike Rounds, John Thune, Lamar Alexander, Bob Corker, Lindsey Graham.

Still skeptical: One senior GOP aide dismissed the chances for actual progress, given that the conservatives and moderates want completely different things: "This is just the death rattle."

Trump's joking plea to Rand Paul: Per three sources, Trump asked Paul — a conservative holdout who is viewed as "ungettable" — to go play golf for three days. Trump said he'd even play golf with Paul for three days himself, just to get him off of TV bashing the Senate bill all the time. Trump said it in a light-hearted tone and laughter broke out in the room.

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Senate health care attempt may not be dead yet

Andrew Harnik / AP

Three Republican senators say they'd vote against a bill repealing the Affordable Care Act without replacing it — but contrary to popular belief, the bill may not be dead yet, according to senior GOP aides. Republican leaders are thinking of scheduling the procedural vote tomorrow morning, the aides said, and the White House is still pushing for the Senate to pass something before it leaves for August recess.

Sens. Susan Collins, Lisa Murkowski and Shelley Moore Capito are being encouraged to vote yes on the first vote, which begins debate on the bill, one senior aide told me. There would then be debate and an opportunity to amend the bill while it's on the floor. So while Majority Leader Mitch McConnell has told members the vote will be on the 2015 repeal bill, the final bill voted on could end up being something else.

"Members are free to do whatever they want out there on the floor, including arranging deals amongst themselves," a second senior GOP aide said. But, echoing one popular opinion among Republicans, the aide was skeptical there's a path forward. "No further use in trying to animate a corpsicle. Time to move on."

But two of the three holdouts would have to agree to vote yes on the motion to proceed if the vote is held before Sen. John McCain returns from surgery. That's a big if, and some are skeptical: "No one believes a deal can be made at this point. The three ladies are waaaay smarter than that," a third senior aide told me.

Keep in mind: Even a failed procedural vote doesn't kill the bill forever. If the first vote on to begin debate on the bill fails, the GOP can always try again. The legislative vehicle will remain intact as long as debate doesn't begin.

On the other hand, many members are saying it's time to work with Democrats on bipartisan approaches. Health, Education, Labor and Pensions Committee Chairman Lamar Alexander said in a statement Tuesday afternoon that the committee will be holding hearings "exploring how to stabilize the individual market."

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Republicans scramble for new direction on health care

J. Scott Applewhite / AP

Congressional Republicans presented anything but a unified front on Monday night after Sens. Mike Lee and Jerry Moran announced their opposition to the Senate health care bill, killing it at least in its current form. Some immediately called for a straight repeal bill, while others discussed alternative replacements and still others acknowledged the party is far from being able to pass anything now.

Senate Majority Leader Mitch McConnell announced that the next step will be a straight repeal vote, with no replacement for the Affordable Care Act. That's what President Trump wants, even though insiders say it has no chance of passage in the Senate. "Republicans should just REPEAL failing ObamaCare now & work on a new Healthcare Plan that will start from a clean slate. Dems will join in!" he tweeted shortly before McConnell's announcement.

Contrast with this: "Thank god. Now the bill can die," one senior GOP Senate aide texted.

The White House quickly made clear it doesn't want Congress to give up. "We look forward to Congress continuing to work toward a bill the President can sign to end the Obamacare nightmare and restore quality care at affordable prices," said a White House spokesman.

What we're watching: If the party can consolidate around any particular direction. If not, things are going to get nasty.

What comes next:
  • House Freedom Caucus Chairman Mark Meadows: "Time for full repeal of #Obamacare--let's put the same thing on President Trump's desk that we put on President Obama's desk." (A reference to a 2015 repeal bill passed through the same Senate process.)
  • Conn Carroll, a Lee spokesman, on what he wants next: "Full [Consumer Freedom Amendment] or 2015 repeal bill." He's referencing an amendment he worked on with Sen. Ted Cruz, which was amended in this version of the Senate bill.
  • Sen. Lindsey Graham on his proposal to turn health care over to the states: "Graham-Cassidy is the conservative approach to solving the problems Obamacare created."
  • Sen. John McCain, who's recovering from surgery: "The Congress must now return to regular order, hold hearings, receive input from members of both parties, and heed the recommendations of our nation's governors so that we can produce a bill that finally provides Americans with access to quality and affordable health care."
  • The senior aide: "I will reserve judgment until after [Senate GOP caucus] lunch [on Tuesday]. Let's see what those two want. They are in very different places."
  • A second senior GOP aide: "How many more changes could possibly be made at this point. We're talking about people on the absolute ends of our spectrum. Every time you move toward one you move away from the other."
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With health care vote delayed, no CBO score Monday

Pablo Martinez Monsivais / AP

The Congressional Budget Office won't be releasing a score on the revised health care bill as planned on Monday, a senior Senate GOP aide tells me.
A vote to move forward with the bill has been delayed while Senator John McCain is in Arizona recovering from eye surgery. Republicans needed his vote to start debate on the bill, with Rand Paul and Susan Collins both already in the "no" column.
For context: Previous scores of both House and Senate plans have found that millions fewer Americans would have coverage, causing significant backlash from members.