Mar 24, 2017

Axios Vitals

Good morning...So like I said, today is definitely the day when the House will vote on Trumpcare. Do they have the votes? Not really. Will they get them? Guess we'll find out. Oh, and the polls look horrible for anyone who votes for it.

Be sure to follow all the latest at the Axios health care news stream, because we're going to stop predicting what happens next. And while you're at it, sign up for our breaking news alerts here.

The state of Trumpcare: Failure is an option

Here's the reality that President Trump and Republican leaders are facing: They want to repeal Obamacare, but not the popular parts of Obamacare. But to the most conservative Republicans, and their supporters, repeal means repeal — which includes everything, whether it's popular or not.

That's why Trump and GOP leaders haven't been able to close the deal with the Freedom Caucus, and will have to try to steamroller them with today's vote. It's why they have the Koch brothers after them. And it's why, barring a miraculous turnaround, they're not getting any closer to a deal that can survive the Senate as well as the House.

Here's where things stand as of this morning:

  • The House is voting on Trumpcare today, whether they have the votes or not. Why? Because Trump told them to.
  • Office of Management and Budget director Mick Mulvaney "made it clear that they were done negotiating, and this is a conservative package that lowers costs," House Ways and Means Committee chairman Kevin Brady told reporters last night. Jonathan Swan has great details of how Trump's ultimatum went down.
  • The big concession White House and GOP leaders are making to conservatives: They're going to get rid of Obamacare's "essential health benefit" requirements, which were untouched in the original bill. Under the new language, states would define them.
  • But the Freedom Caucus wanted to go beyond that, into the rest of Obamacare's insurance regulations — which include popular things like covering anyone with pre-existing conditions, making sure sick people can't be charged more, coverage of young adults, coverage of preventive care, and standards for how much of a person's medical expenses are covered.
  • If Trump and GOP leaders had agreed to wipe out the pre-existing condition coverage, they would have lost one of their main pitches for the Republican plan: Don't worry, sick people will still be covered. "I think that's been something that he's been very clear needs to stay in there," White House press secretary Sean Spicer told reporters.
  • But Freedom Caucus members and other conservatives say all of the insurance regulations make insurance more expensive — so to be consistent, they should all go. (Freedom Caucus member Mark Sanford's Obamacare replacement bill would deal with pre-existing conditions by giving sick people two years to enroll in coverage.)
  • The Washington Post reports that Freedom Caucus chairman Mark Meadows wanted to get rid of not just the rules against charging more for sick people, but also provisions that most Republicans have sworn they would never touch, like the ban on annual and lifetime limits on health benefits.
  • Meadows was still a "no" as of last night.
The Senate might be slower

Yeah, that's an evergreen headline, but it's important in this case. Senate Majority Leader Mitch McConnell had hoped to take up the Trumpcare bill as soon as the House was done with it, but now that the House is changing the essential health benefits, that may not be possible. A Senate Republican aide tells Caitlin Owens that they'd have to wait for new Congressional Budget Office estimates, which could take as long as seven to 10 days: "We are in wait and see mode and then we will react. We are likely on a much slower path."

But at least it's massively unpopular

This Qunnipiac University poll was a big wakeup call for Republicans yesterday: Americans oppose the GOP bill by a 3 to 1 margin. But wait, you say — wasn't Obamacare pretty unpopular at this point in its passage, too? Yes — but in that case, the public was just evenly divided on it, according to a Washington Post poll in November 2009.

That should have been a warning sign too, and it set the pattern for the public opinion troubles that followed. But if you think Obamacare had problems with the public, imagine what happens if Trumpcare becomes law.

Obamacare, November 2009:

  • Support: 48 percent
  • Oppose: 49 percent

Trumpcare, March 2017:

  • Support: 17 percent
  • Oppose: 56 percent
The cost of the Obamacare insurance regulations ...

The Freedom Caucus isn't making it up when they say Obamacare's insurance regulations have made individual coverage more expensive. Insurers have been saying that for years, which is why they've wanted more flexibility.

One industry analysis, I'm told, estimated that individual health insurance premiums increased by 50-60 percent in just two years — between 2013, the year before Obamacare's main insurance regulations took effect, and 2015. That includes 13-17 percent from the essential health benefits. But the biggest increase — 30-35 percent — was due to "guaranteed issue," the requirement to cover pre-existing conditions.

And in a Fox News column, Stanford's Lanhee Chen, a member of the Axios board of experts, cites a 2013 report by eHealth, Inc. that said individual health plans with benefits similar to Obamacare's essential benefits were 47 percent more expensive than plans that didn't have them.

... and why the regulations are there

But the Kaiser Family Foundation has a good reminder of why the law added all of those regulations in the first place: because 27 percent of non-elderly adults were shut out of the market because of health problems. They dealt with things like multiple-page questionnaires about their health status, lots of different rates, and health plans that left out major categories of benefits, like prescription drug or mental health coverage.

And for anyone who thinks the Republicans should just get rid of the essential health benefits but leave the pre-existing condition coverage in place, the Center on Budget and Policy Priorities has this reality check: they're linked. If insurers don't have to cover those broad categories of benefits, the center writes, they'd steer sick people away by cutting benefits and raising out-of-pocket costs.

The kicker: You like having no annual or lifetime limits? Those are tied to the essential health benefits — so if you get rid of those, the ban on those payment limits would be "meaningless."

The Disneyland vaccine jump

Remember that big measles outbreak in late 2014 that originated in the germ haven of Disneyland and spread because some people weren't vaccinated? Turns out it spurred parents to get their kids to the doctor, Bob Herman reports. Roughly 45 percent of California babies had the measles vaccine in 2014, but that jumped to 62 percent by the end of 2015, according to data from the health IT company Athenahealth. The increase is partially attributed to California creating some stricter vaccine requirements, partially attributed to fears of getting an infection from riding the teacups.

One way states could help bring costs down

While everyone is transfixed over the "repeal and replace" fight — which is only about who gets what kind of insurance, if any, to pay the exorbitant cost of care — Steven Brill flags this important piece in Health Affairs that might go unnoticed.

Which it shouldn't. It's about the only plan to control costs that has actually been working, Brill notes. States such as Maryland continue to make progress using state rate setting regimes, which bring not just prices, but the volume of the services under control. "Rate setting works," report authors David Frankfort and Sara Rosenbaum, "because it consolidates the demand-side, thereby enabling the assertion of collective bargaining power and control of expenditures."

What we're watching today: House Trumpcare vote. Expected to start between 4 and 5 p.m. Eastern, per House Majority Leader Kevin McCarthy's office.

What we're watching next week: Depends what happens with the Trumpcare vote.

Thanks for reading, and stay tuned: