Happy actual Friday! We're getting a better picture of the Obamacare replacement plans the House committees will start working on after the recess. But they're still figuring out critical details, like any numbers at all, and they're nowhere close to getting all Republicans on board.
Surprise! It was "A Better Way" all along
We've all been in suspense, chasing the details of what House Republicans will do to replace Obamacare — and now it's clear we could have been reading House Speaker Paul Ryan's "A Better Way" plan the whole time. The briefing document from yesterday's House Republican meeting sticks closely to the Ryan plan from last year, at least in the parts it includes.
The big things that are being picked up from "A Better Way":
- Tax credits (fixed amounts, based on age, not income)
- Health savings accounts
- Medicaid reform (choice between per-capita caps and block grants)
- "State Innovation Grants" (can be used for high-risk pools)
The big pieces that are left out:
- Limiting the tax breaks for employer health coverage (Republicans are still talking about it)
- Medicare "premium support" plan (President Trump's not interested)
The backstory: None of this should be a surprise. Ryan has been the driving force in the House on health care reform all along, and he noted yesterday that his former colleague, Health and Human Services secretary Tom Price, was "one of the primary architects" of the Better Way plan. The Senate still has to buy off on it, but the thinking among House GOP aides is that the House has more leverage because Ryan has been working on these ideas for years.
They haven't solved the Obamacare Lite problem
The big signal that House Republican leaders are sending with the Obamacare replacement plan: The Freedom Caucus doesn't get to run the show.
- The conservatives have insisted that the law needs to be repealed before they worry about a replacement. And earlier this week, Rep. Raul Labrador said they don't want to pass anything that looks like "Obamacare Lite" — another huge overhaul of the health care system that just happens to be more conservative.
- But House Republicans are clearly headed for an ambitious overhaul, and they even brought in Price to tell the rank and file that President Trump wants the repeal and replacement to happen at the same time.
- Labrador made it clear the new plan didn't avoid the "Obamacare Lite" trap. "No," he said when I asked him. "So far it just sounds like Obamacare Lite."
- He said he wanted to find out more about it, but "there were only two minutes of time for members to ask questions." Rep. Jim Jordan had the same complaint.
Why it matters: The House leadership is calling the bluff of the Freedom Caucus — but they do need their votes to pass the plan. And then they'll have to keep the conservatives on board if the Senate tries to moderate the plan.
FWIW: Caitlin Owens reports that none of the Senate Republicans she asked had read the House plan. They didn't know it was out.
Ryan on the big problem: Medicaid
Here's what Ryan said at his weekly press conference yesterday: "I think it's 32 states, if I am not mistaken, have Medicaid expansion. Mine did not. We're going to have to find a solution that accommodates each of these two concerns."
What's in the plan: States that expanded Medicaid could keep getting their extra federal funds "for a limited period of time," but they'd go back to the regular federal matching rate "at a date certain." Republicans are still figuring out what those dates will be, but the goal is to stop the states that expanded Medicaid from enrolling new people.
What's missing is what matters the most
The briefing document lays out all of the ideas but includes almost none of the specifics that really matter, like the size of the tax credit, the amount of the "state innovation grants," or the ways to pay for all of it. That's partly because Republicans are still getting official cost estimates, but those are the details that will really make a difference, according to outside analysts:
- Harvard's John McDonough, former Senate Democratic aide and member of the Axios board of experts: "What is the size of the credit? Why so shy about this? Why the veil over the most important single item in a plan? Maybe because revealing the number will allow experts to figure out quickly how many will lose coverage."
- Chris Condeluci, former Senate Republican aide and member of the Axios board of experts: Key questions are whether it really repeals all Obamacare taxes right away or phases some out gradually, and how to be fair to states that expanded Medicaid and the ones that didn't.
- Zeke Emanuel of the Center for American Progress: "How much is the subsidy? We don't know their value so we cannot say what it will cover ... There is not enough information but what appears is that people will pay more and many people will find insurance impossible to buy."
How the FTC’s new competition chief could affect health care
President Trump's acting Federal Trade Commission chairwoman, Maureen Ohlhausen, is wasting no time shaking up the agency. Bob Herman reports that she named Tad Lipsky the new acting director of the FTC's Bureau of Competition yesterday — the office charged with policing mergers and acquisitions for most of the health care industry.
What this means: Potentially less oversight, but not for all health care players. Lipsky replaces Deborah Feinstein, who went after some large hospital and health system mergers. However, her group has been lax on many transactions involving drug companies, pharmacy benefit managers and retail pharmacies.
- Former FTC staffers say Lipsky is a pro-business conservative who is less aggressive in challenging M&A, but he also is knowledgable about health care and likely won't slow down reviews on hospital mergers.
- Former FTC antitrust attorney John Kirkwood: "This is not choosing a Steve Bannon ... This is like choosing another establishment figure to the right of Debbie Feinstein."
Key quote: Here's what Lipsky said to U.S. News & World Report in December after Trump won: "The purpose of antitrust is not necessarily to prevent firms from succeeding, even when they become very dominant in their industry."
A few big moments at the Seema Verma hearing
The Centers for Medicare and Medicaid Services nominee didn't answer all of the questions at the Senate Finance Committee hearing yesterday — especially on the new Obamacare rule, which came from the agency she'll be running. But there were a few standout moments:
- She defended the Indiana approach to Medicaid, which requires low-income people to contribute to their health care: "It gives dignity to individuals ... We don't assume that just because someone is poor, they don't want choices about their health care."
- She said she doesn't support what Sen. Bill Nelson called a "voucher" system for Medicare, meaning the premium support model that Ryan wants — a sign that the Trump team has given her full permission to brush it away.
- She might actually be a fan of pharmaceutical benefit managers, which are taking a lot of grief lately for their possible role in contributing to rising drug prices.
- She said the MACRA bill, which reformed how Medicare pays doctors, was an "important step forward" for outcomes and providers.
For more highlights, read Caitlin Owens' roundup here.
For more Obamacare replacement light reading ...
Republicans went on a tear yesterday with the bill introductions, as they unloaded more details of other pieces of Obamacare replacements. Bookmark these and make someone read them for you:
- House Energy and Commerce Committee chairman Greg Walden's pre-existing conditions bill.
- Senate Finance Committee chairman Orrin Hatch's health savings accounts bill.
- Rep. Sam Johnson's association health plans bill.
Between the lines: The pre-existing conditions bill reads a lot like Obamacare — it looks like Republicans suddenly decided to just cover all sick people. But it's supposed to be paired with a "continuous coverage" bill, which would allow people to be charged more if they didn't keep themselves insured. It's also possible that the Trump administration will take some of their own steps to promote continuous coverage, as we noted yesterday.