Apr 6, 2017

Axios Vitals

Good morning ... Trumpcare's dead again, for now, we guess, until it comes back to life and maybe dies again. We get the parallels Republican leaders try to draw — Obamacare sputtered and died before coming back to life, too. It's only April. But this is a lot of sputtering and dying.

The quick, painful re-death of Trumpcare

Looks like Trumpcare isn't going to make a pre-recess comeback after all. The White House would have loved to at least get a new health care agreement before the congressional recess, and a lot of Republicans would have liked it too. Instead, they're going to head into the two-week break with nothing more than the knowledge that at least they didn't murder each other.

The root of the problem: House Republicans, as a group, can't reconcile their promise to cover people with pre-existing conditions — one of the most popular parts of Obamacare — with the fact that it makes individual health insurance more expensive. Conservatives think it's OK to let states put all of the sick people in high-risk pools. The rest of the Republicans don't. Hard to see how that changes after a two-week break.

Here's how nasty it got yesterday as everything fell apart:

  • Heritage Foundation CEO Michael Needham blamed moderate Republicans for the collapse of the talks, and called out three by name for allegedly breaking their promises to repeal Obamacare.
  • One of the ones he called out, Rep. Leonard Lance, later told reporters that he has "repeatedly campaigned" on the promise of protecting people with pre-existing conditions when Congress repeals and replaces Obamacare: "I have never campaigned on pure repeal, ever."
  • Another moderate, Rep. Tim Murphy, said the "community rating" provision — which bans insurers from charging higher rates to sick people — "needs to stay in as it is."
  • Even Patrick McHenry, the chief deputy whip, acknowledged to reporters that he's aware of the "really bad practices in the insurance marketplace" before Obamacare, per Bloomberg: "My family history is really bad. And so my understanding of the impact of insurance regs is real."
  • But Needham said the compromise that was being discussed on Monday — before being substantially narrowed last night — was a major concession by conservatives, because it would have let the Obamacare regulations survive as a starting point.
  • States could have gotten waivers if they could convince HHS that they could provide "better coverage," Needham said — which the states would have to define.
  • By the end of the day, the effort fizzled, and the expected next round of meetings with Vice President Mike Pence didn't happen.
  • Instead, Pence got an update from House Speaker Paul Ryan and Majority Leader Kevin McCarthy on "the progress made this week on health care and the next steps toward keeping our promise," according to a senior Ryan aide. They also met briefly with President Trump.

What's next: Needham said Heritage Action might try to put pressure on the moderates over the recess. But McHenry said the recess could be a valuable "cooling-off period," per the Washington Post.

Is it dead for good? Don't bet on it. Ryan, at at an event hosted by the WisPolitics news service: "We can keep working this for weeks now. We don't have an artificial deadline."

Things you may or may not hear about again

From Trump's interview yesterday with the New York Times: He might link the health care bill to his infrastructure plan.

"We want to do a great infrastructure plan, and on that side I will say that we're going to have, I believe, tremendous Democrat support. We are also going to have some good Republican support, and I think it's going to be one of the very bipartisan bills and it's going to happen. I may put it in with health care."

Why it matters: It could be something he forgets about tomorrow, but when the president thinks out loud about combining an unpopular health care bill with a popular infrastructure plan, you should at least be aware of it.

Why Ryan won't twist arms on Trumpcare

Needham was adamant yesterday about what Ryan needs to do on Trumpcare — knock some Republican moderate heads. "It is the job of Paul Ryan to get them to vote 'yes' on a reasonable proposal," he told reporters on a conference call.

Here's why that's not going to happen. As Ryan explained it at the WisPolitics event, he doesn't want a "top-down" process — he wants rank-and-file members to talk to each other, hear each others' concerns, and build a consensus. "I want an organic, bottom-up process....You can't do that if leadership is just ramming and being autocratic."

And McCarthy isn't going to be the bad cop, either. "I want to win with the power of the idea rather than the power of the stick," he said at our Axios/NBC News health care event yesterday.

Next up: Medicaid and tax reform?

File this under "chatter to be aware of": Caitlin Owens reports that some Senate Republicans have been talking about reviving their Medicaid rewrite plans even if there's no Trumpcare. Why? Because Republicans have always wanted to rein in the costs of Medicaid, and if they do it, they might get some of the money they'd need for tax reform.

Why it might matter: There's been a lot of idle talk about scenarios for reviving GOP health care plans since the first collapse of Trumpcare. It doesn't sound like the Medicaid talk is too serious at the moment — one aide characterized it as side conversations — but it's Congress, and you never know where the talk might lead. Remember, no one thought Trumpcare would come back either, until it did (and then went away again). Read Caitlin's story here.

So much for Virginia Medicaid expansion

Another possible new Medicaid expansion has been stopped. Virginia Gov. Terry McAuliffe wanted to amend the state budget to allow the expansion, saying there was no point in holding off after Trumpcare fell apart. But Republican lawmakers blocked his amendment yesterday, insisting that Virginia can't afford it, the Wall Street Journal reports.

Another plot twist with the lines around the states

House Republicans still want to pass a bill allowing health insurance to be sold across state lines, thinking that would give people more ways to buy cheaper health insurance. But a new analysis from the Commonwealth Fund tells us why that won't do much good: The "primary barrier for an insurer looking to enter a new market is not the state's regulations, it's the cost of building up a provider network at discounted prices." It's a practical problem that you won't hear about much in the hyper-polarized ideological debates.

Didja know? There's another catch, as I was reminded yesterday by a former Democratic staffer: There's already a provision in Obamacare that allows health insurance to be sold across states. The catch, though, is that the other states have to agree to it — so a really cheap health plan from, say, Mississippi can't be sold in more heavily regulated New York unless New York officials say it's OK. That's not what the GOP idea is, though. They want to be able to get around the mandates of the more heavily regulated states (because that's what makes health insurance more expensive).

If the insurers all run away from Obamacare ...

There's going to be a lot of debate about why. Former Health and Human Services secretary Kathleen Sebelius made it clear at our Axios/NBC News event why she thinks it's a danger: because of the endless back-and-forth over whether the Affordable Care Act will be repealed, and what will happen to payments to insurers in the meantime. "Unfortunately the uncertainty over what's going to happen … is creating, I think, a fleeing from the marketplace, not stability," she said.

Republicans aren't buying it, though. Murphy says he has talked to insurance company officials who are worried about the payments, but their bottom line is that "the ACA is unaffordable to them." He insists the problem is with the design of the law: "If you buy a lemon car, and you try to get it repaired, and you can't get it repaired, it's the manufacturers' fault."

The passengers want it fixed: Meantime, the Alliance of Community Health Plans is asking congressional leaders to stop fighting and just get them the subsidy payments: "The lack of clarity...as we near individual market rate filing deadlines means that millions of people are at risk for increased health insurance premiums."

Thanks for reading, and shoot me a note if there are big things happening in your corner of health care world: david@axios.com.