Good morning ... The Senate is still planning to vote on something related to health care next week, but no one knows which proposals will get a vote or what might pass. Asked by The Hill yesterday whether senators might want to know what the plan is before they vote on it, Sen. John Cornyn said that's "a luxury we don't have."
So, that's where things are. Full speed ahead toward ... who knows.
The Senate: chaos and contradictions
Lazaro Gamio / Axios
The latest: Our colleague Caitlin Owens is hearing that the Senate parliamentarian is set to deliver her verdict on the GOP's health care bill today, deciding how much of it — if any — will need to be tossed out because of the Senate's budget rules.
Why this matters: The parliamentarian's rulings could significantly alter the bill's political prospects, either by forcing out regulatory rollbacks and abortion restrictions that were key to winning over conservative senators, or by challenging some of the one-off giveaways to moderates.
Note: We're not expecting a public announcement today, just a briefing with senators.
Meanwhile: Senators left town for the weekend without seeming to move any closer to a deal to pass anything — and also without a ton of consistency just within their own statements and policy positions. Some have flip-flopped on whether Congress should simply repeal the bill, or repeal it and replace it at the same time. Others have slammed its tax cuts, then complained they haven't gone far enough.
It's been hard to keep up, but Caitlin compiled some of the most notable reversals. Check it out.
The $13,000 deductible
Data: Kaiser Family Foundation; Chart: Chris Canipe / Axios
The new Congressional Budget Office report on the revised Senate health care bill was an important lesson in the tradeoffs in health insurance. Yes, it suggested that premiums could go down for some groups, which has been one of Republicans' main goals. But because the "actuarial value" of the coverage could go down — meaning customers would have to pay more of the medical costs themselves — the deductible for a low-income person could shoot up to $13,000.
For context: That's about half the income of someone at 175% of the federal poverty level. And for someone at 75% of the federal poverty level — the kind of person who's supposed to gain private coverage in states that didn't expand Medicaid — it's more than their entire annual income.
The bottom line: Premiums aren't everything. You can make the premiums lower, but the deductibles will be higher — so all you did was make the customer trade one kind of health care spending for another.
Why Trump’s $12 health insurance matters
Here's the passage from President Trump's New York Times interview that lit up health care Twitter yesterday:
So pre-existing conditions are a tough deal. Because you are basically saying from the moment the insurance, you're 21 years old, you start working and you're paying $12 a year for insurance, and by the time you're 70, you get a nice plan. Here's something where you walk up and say, "I want my insurance."
We really are not trying to give Trump a hard time every time he talks about health care. But here's why this statement matters:
- Nobody pays $12 a year for health insurance.
- There are people who pay very little for insurance, but that's if they're getting Affordable Care Act tax credits.
- What he described — with the "nice plan" at 70 — is something closer to life insurance, as several wonks pointed out.
- It's not that the mistake itself makes a big difference in health care negotiations. It's that it speaks to a broader concern senators have had about Trump's understanding of the system Republicans are trying to change.
- If Trump doesn't have a basic idea of the cost of health insurance, how would he understand the complexities of how the Senate health care bill could affect people's lives — like why its changes in actuarial value could end up with people paying $13,000 deductibles?
- Trump doesn't show any awareness of his knowledge limits, per this quote from the same interview: "Actually, these guys couldn't believe it, how much I know about it. I know a lot about health care."
The White House response: Sarah Huckabee Sanders, when asked about the claim at yesterday's press briefing: "I'll have to check on the specifics."
Here’s how expensive brain cancer is
On top of everything else, Sen. John McCain is looking at a lot of medical expenses for his treatment for glioblastoma — a nasty, aggressive form of brain cancer. He's likely to have a lot of those expenses covered, but not all — and a brain cancer patient with less generous insurance would be even worse off. (Which is one reason advocates for cancer patients are so worried about the Senate health care bill.)
Per the National Brain Tumor Society:
"Brain tumors have the highest per-patient initial cost of care for any cancer group, with an annualized mean net cost of care approaching $150,000, as well as the highest annualized mean net costs for last-year-of-life care relative to other cancers at $135–$210K (depending on age and gender) per-patient."
Next up on the FTC’s competition bureau carousel
D. Bruce Hoffman will fill the void of acting director of the Federal Trade Commission's Bureau of Competition — the office that reviews most health care mergers left vacant by Tad Lipsky after a short five-month stint, Bob Herman reports.
Hoffman is a corporate antitrust lawyer who worked in the same FTC bureau during the George W. Bush administration. Hoffman is "colorful" and an "excellent speaker," according to Jack Kirkwood, who worked with Hoffman at the FTC. He's also a mainstream conservative like Lipsky. "We're not talking about a Scott Pruitt or a Tom Price," Kirkwood said.
Health care hook: Hoffman co-authored an article in 2010 about mergers and "exclusionary conduct." His view: Regulators shouldn't block a merger based on the grounds it could lead to anticompetitive behavior. They should wait to see what actually happens — a policy hospitals and others in health care would prefer over the FTC's current heightened antitrust enforcement.
Here’s what Democrats mean by ACA fixes
Democrats keep saying they're ready to work with Republicans on fixes to the ACA once repeal is off the table, and House Minority Leader Nancy Pelosi made the same pledge yesterday. But the kinds of fixes they have in mind don't have a lot in common with what Republicans want.
Here's what their leading ideas are, as described by Pelosi and four top committee Democrats at a press conference yesterday (and by Senate Minority Leader Chuck Schumer to the Washington Post earlier this week):
- Fund the cost-sharing reduction payments permanently
- Make permanent the temporary ACA reinsurance program
- Beef up the ACA tax credits
- Give new options to people in rural counties without insurers, like letting them buy into the D.C. health exchange
Reality check: Republicans aren't likely to settle for these kinds of steps without any changes to ACA rules. Cornyn has repeatedly said he won't support what he calls "insurer bailouts" without any changes to the structure of the ACA.
What’s the opposite of outreach?
HHS, under secretary Tom Price, is significantly pulling back — if not directly counter-programming — enrollment outreach for the ACA's insurance exchanges.
- The administration has decided not to continue a pair of outreach contracts that supported enrollment efforts in 18 cities, the AP reported yesterday. Together, the two outreach firms had helped sign up about 14,500 people. A spokeswoman said the contracts were never intended to be long-term, and that other programs, including enrollment call centers, would continue.
- And the Daily Beast reported that HHS has tapped its outreach budget to film as many as 130 videos criticizing the ACA.
Why it matters: The ACA has problems. If Congress fails to pass its own changes to the law — which looks pretty likely — one of the best ways to solve the ACA's problems would be to get more young, healthy people to sign up. But that takes outreach work — and an interest in actually fixing the law's weak spots.
What we're watching next week: Senate votes on motion to proceed to some kind of health care bill. Also, House Energy and Commerce health subcommittee hearing on Medicare Advantage Special Needs Plans, Wednesday.
Lots of earnings calls, too. HCA, Tuesday before markets open; Anthem, Wednesday before markets open; Gilead Sciences, Wednesday after markets close; Zimmer Biomet, Thursday before markets open. And Biogen and Alexion Pharmaceuticals will have "strategic updates" in addition to earnings.
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