Jul 13, 2017

Axios Vitals

By Caitlin Owens
Caitlin Owens

Good morning ... Senate Republicans are set to release their revised health care bill today. Drink once every time a senator says "I haven't had a chance to read the bill yet" and twice for every "I'm waiting for the CBO score." If Dean Heller and Susan Collins say they're still opposed, finish your drink and buy one for Mitch McConnell.

Don't forget to check the Axios health care news stream throughout the day for, you know, news.

Here comes the brand new Senate health bill

One important thing to keep in mind as Senate Republicans unveil their revised health care bill today: This is not necessarily the final bill. The parliamentarian could still change it. Negotiations with individual senators could still change it.

Even if Sen. Ted Cruz's consumer-choice proposal makes it in, that policy also could still change. At a minimum, lawmakers will need a new score from the Congressional Budget Office. So, we're not done yet.

All of that said, here's what we're expecting from version 1.1:

  • Broadly the same as version 1.0, without any major changes to the Medicaid provisions.
  • Some of the Affordable Care Act's taxes on wealthy people would no longer be repealed.
  • More money for the bill's "stabilization fund" — which is to say, more money to help the states keep premiums under control.
  • A new provision to allow people over 30 to buy high-deductible plans (per Caitlin Owens).
  • As much as $45 billion in new money to combat the opioid crisis.

If Republicans were moving any closer to a deal yesterday, they didn't show it. Among the rotating cast of senators most likely to keep the bill shy of 50 votes, no one seemed to be softening — if anything, some opponents seem to be hardening.

  • Sen. Rand Paul, whose vote was already gone, reiterated his opposition yesterday.
  • The bill's moderate critics — including Sens. Susan Collins, Shelley Moore Capito and Lisa Murkowski — are still concerned about Medicaid, and for now, the Medicaid cuts seem locked in.
  • The insurance industry's opposition to Cruz's consumer-choice plan won't help it win moderate support, and if it doesn't find a way into the bill, Cruz, Mike Lee and (potentially) Ron Johnson are likely out.

Republican senators will learn the details about the new bill at an 11:30 briefing.

Why the right thinks it's unpopular

There are a lot of different ways to read the lousy poll numbers for the GOP health care effort. On the left, the lesson is obvious: They think it's a terrible bill that takes away people's health care. The more surprising takes are coming from the right.

As conservative leaders have correctly pointed out, repeal of the ACA was a popular position for Republicans in four elections. So why is the actual repeal bill so unpopular? A few smart takes from our conversations with conservative groups:

  • It's not a straight repeal bill, which is all that most conservative activists really wanted. "They're less interested in replace than repeal," said Jason Pye, VP of legislative affairs for FreedomWorks.
  • It doesn't even repeal many of the biggest elements of the ACA, like the insurance regulations and the subsidies. "You don't get an approval rating that low unless you're irritating your base," said Dan Holler, VP of Heritage Action for America.
  • The public doesn't understand the bill, and Republicans aren't explaining it with conviction because they "never came to a consensus, publicly and internally, about what they're trying to do," Holler said.
  • The news coverage has been negative and damaging, Pye said — especially when talking about the CBO estimates of coverage losses, which conservatives (and the Trump administration) believe are inflated.

Why it matters: This is not just a case of "they need to communicate it better." The GOP never did get on the same page on what they wanted on health care, other than repeal. And a divided army can't fight back when it's under fire.

The Blues are all over the place

Blue Cross and Blue Shield insurers are invested in (and vital to) the ACA marketplaces, as Bob Herman explained in April. So you would think they would coalesce around one set of reform ideas. But as Bob points out, the Blues are a fractured alliance right now.

  • Dan Hilferty, CEO of Independence Blue Cross, released a statement last month that supported a lot of the Senate health bill. But he said there needs to be "additional dialogue" about Medicaid, which faces $772 billion of cuts over the next decade.
  • Independence's stance matches pretty closely with Anthem, the for-profit Blues company and the largest of all the brands. Anthem didn't say much about the Medicaid cuts, which is odd considering Anthem is a major state Medicaid contractor.
  • Those views contrast with Blue Shield of California CEO Paul Markovich, who firmly opposes the Senate bill.
  • Most of the other Blues have blamed Washington for big ACA premium hikes next year, but have kept their mouths shut on the Senate bill, deferring to the Blue Cross Blue Shield Association.

The bottom line: It's difficult to imagine any Republican plan passing without getting support of most of the Blues plans. But the Blues lack consensus within their own membership, making the task harder.

Price may have to implement the ACA's Medicare cuts

Medicare's trustees are set to deliver their annual report on the program's finances today. And there's a decent chance they'll say that Health and Human Services secretary Tom Price needs to make some cuts to the program — cuts he described as "rationing" when he was in the House.

What's happening: The ACA set up a new independent board — the Independent Payment Advisory Board — to make targeted Medicare cuts if the program's overall spending grew especially quickly. (Then-Rep. Price slammed it as an "unaccountable, unelected board of 15 bureaucrats" with "the power to deny care to seniors.")

No one was ever appointed to that board, and spending hasn't grown enough to trigger it, anyway. But some experts think this might be the year it crosses that threshold. And because no one's on the board, it would be up to the HHS secretary to decide where to cut.

Why it matters: Price has already shown that he's not eager to enforce the ACA any more than he has to. But, technically, this is an area where he might have to. Conservative Republicans like Price have called for lower entitlement spending for years, and yet this board was a central part of their attacks against the ACA.

Oh yeah, and the House passed the FDA user fee bill

That's all. The Senate still has to pass its bill. Might happen before the August recess.

Sorry guys, we've forgotten how to write about health care bills that nobody's fighting about.

The subtle sarcasm of the Labor-HHS bill

When Congress releases an appropriations bill, it always compares its funding levels with the president's budget request. Usually it will say a program's funding level is a bit above or a bit below the president's budget.

But when the House released its Labor-HHS funding bill yesterday — which will be taken up by an appropriations subcommittee today — its summary made it clear how extreme the cuts would have been if the House had followed the Trump budget:

  • HHS: "$14.5 billion above the President's budget request"
  • National Institutes of Health: "$8.6 billion above the President's budget request"
  • Centers for Disease Control and Prevention: "$1 billion above the President's budget request"
  • Administration for Children and Families: "$4 billion above the fiscal year 2018 request"
  • Agency for Healthcare Research and Quality (which gets a slight cut): "The budget request proposed to merge most of AHRQ's activities into NIH"

Yes, but: There are still enough cuts to guarantee fights ahead. More here.

Why Clinton’s Medicaid per-capita caps were different

One of the Republicans' favorite talking points about their Medicaid per-capita caps plan is: "Bill Clinton tried to do it too." And it's true — Clinton did have a Medicaid per-capita caps plan in 1995. But that's where the similarity ends, according to Gene Sperling and Chris Jennings, two of the former president's top advisors.

What's the difference? Here's what they wrote in The Atlantic yesterday:

  • Clinton's plan was meant to defeat congressional Republicans' plans to turn Medicaid into block grants.
  • The point of Clinton's plan was to preserve Medicaid's status as an entitlement program, rather than ending it.
  • It was never supposed to produce big savings. The Senate GOP plan is projected to save $772 billion over 10 years. Clinton's savings? $6 billion over five years.
  • There was more fat to cut in Medicaid spending in 1995 than there is now.

Reality check: This is all correct as far as it goes (David covered the Medicaid battle at the time). But all that most people will hear is that Clinton did, in fact, propose per-capita caps. The one difference that may stick is that the Republicans' savings are much, much deeper.

Caitlin Owens

What we're watching today: Look for Senate bill 1.1 to post online around 11:30 a.m. Eastern, and the new Medicare trustees report comes out this afternoon. Sen. Lindsey Graham may put out his own health care proposal, too.

Also, House Appropriations Labor-HHS subcommittee marks up the HHS funding bill, because why not? 4:30 p.m. Eastern. Livestream here. And House Ways and Means Committee marks up bipartisan bills to update Medicare Part B and reauthorize the Medicare Special Needs Plans program, 2 p.m. Eastern.

What we're watching next week: The Senate passes its health care bill. Or doesn't.

Also, UnitedHealth Group and Johnson & Johnson kick off second-quarter earnings season, Tuesday, July 18. House Energy and Commerce oversight subcommittee hearing on the 340B drug discount program, Tuesday, July 18.