The Health 202: The Senate health-care bill is suffering from crippling unpopularity, too – Washington Post

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THE PROGNOSIS

The Senate GOP health-care bill departs less from Obamacare than the House measure — yet the two remain close cousins. So will the Senate bill suffer from the same crippling unpopularity as the House version? It appears so.

Today, we’re waiting for an official estimate from the Congressional Budget Office of how many people would be covered under the Senate bill compared to under the Affordable Care Act, the law it seeks to overhaul.

Things didn’t go so great for the House GOP health-care bill earlier this spring when the CBO estimated that it would leave 23 million people uninsured. The score fed a major backlash against that bill, which is currently supported by just 30 percent of the public, according to a new Kaiser Family Foundation poll, which also found 51 percent support for the ACA.

Our best guess is the Senate bill will do a little better on the coverage front, but not by much, resulting in a big public image problem for Senate Majority Leader Mitch McConnell to deal with as he tries to push the measure across the finish line this week.

Even if the CBO says the Senate bill will cost fewer people their coverage, say, 18 million or 20 million people instead of the House bill’s 23 million, that won’t be enough to move the needle for Democrats, the health-care industry and others who opposed the House bill on the grounds it would ratchet the uninsured rate back up again — including four Republican governors whose states accepted the ACA’s Medicaid expansion.

Governors John Kasich of Ohio, Brian Sandoval of Nevada, Charlie Baker of Massachusetts and Larry Hogan of Maryland all issued separate statements last week criticizing aspects of the Senate measure, including the secrecy under which it was written as well as the impact it would have on state budgets and low-income residents, my colleague Sandhya Somashekhar reports. Each of their states have received billions more in federal dollars over the past to help them cover more Americans on Medicaid.

The health-care industry didn’t even wait for a CBO score to register discontent with the Senate bill over its cuts to Medicaid and less-generous insurance subsidies. Doctors, hospitals and patient groups overwhelmingly came out against the Senate’s Better Care Reconciliation Act when the details became clear last week.

The American Medical Association said it is still reviewing the bill but has “grave concerns” with its cuts to Medicaid spending. 

The American Academy of Pediatrics said it “fails to meet children’s needs.” The American Academy Of Family Physicians said it reflects many of the same “flawed concepts” in the House bill and in many ways, poses “a graver threat to millions of Americans, particularly children, people with disabilities and older Americans.” The American Hospital Association said the Senate should “go back to the drawing board.”

State Medicaid directors plan to issue a statement today saying the bill’s slower Medicaid growth formula is “insufficient and unworkable.”

“No amount of administrative or regulatory flexibility can compensate for the federal spending reductions that would occur as a result of this bill,” the National Association of Medicaid Directors will say, according to a statement provided to The Health 202.

Not even the bill’s more generous premium subsidies (relative to the House bill), its two-year retention of extra Obamacare cost-sharing subsidies or its repeal of nearly all the ACA taxes won over the insurance industry. “We are not taking a support or oppose position,” Kristine Grow, spokeswoman for America’s Health Insurance Plans, told the Hill.

McConnell made a clear play for the support of moderate senators in crafting his bill. It sticks close to the ACA’s subsidy structure, providing federal assistance to people earning up to 350 percent of the federal poverty level who are purchasing insurance on their own and pegging the subsidies to a benchmark plan.

It takes longer than the House bill to roll back the ACA’s Medicaid expansion, waiting to draw down all the extra federal payments until 2024. And it preserves more of the ACA’s insurer regulations than the House bill, including its requirement for insurers to cover people with preexisting conditions without charging them more.

So if the Senate bill still doesn’t please the health-care industry and those on the moderate end of the spectrum despite shifting in a leftward direction, it certainly doesn’t enthuse conservatives either, who wanted to see even more of Obamacare repealed and are now terming the Senate bill “Obamacare-lite.” Those who had panned the House bill for keeping much of the ACA in place sharply criticized the Senate bill too, or at least said it needs major changes for them to come on board.

From the Washington Examiner’s Phil Klein:

The Koch network, which supports such prominent groups as Americans for Prosperity, is refusing to endorse the measure as it stands, my colleague James Hohmann reported over the weekend. The network is working with conservative allies behind the scenes to make changes to the bill.

“In all candor, we’ve been disappointed that movement is not more dramatic toward a full repeal or rollback (of the Affordable Care Act). But we’re not walking away,” Americans for Prosperity President Tim Phillips told hundreds of donors gathered Saturday for a three-day seminar. “We still think this can get done, but the Senate bill needs to get better.”

AFP came out against the first version of the House health-care bill earlier this spring. So did Heritage Action and FreedomWorks, and neither of those groups are backing the Senate bill in its current form either. From Heritage Action:

FreedomWorks has been quite forthright in its criticism of the Senate bill, charging that it keeps way too much of the ACA and doesn’t fulfill the GOP’s promise to ditch the law:

None of this opposition is likely to dissuade McConnell. If anything, it will motivate him to get the bill past the finish line faster so he can move on to other legislative priorities that aren’t so potentially damaging politically. 

And McConnell is getting praise from a few on the right, who say the Senate bill solves some of the House bill’s problems by better targeting assistance to low-income Americans and giving states more flexibility through the ACA’s existing waiver structure. One of those is Avik Roy, a prominent health-care policy expert who has advised Mitt Romney, Rick Perry and Marco Rubio.

“For decades, free-market health-reform advocates have argued that the single best idea for improving U.S. health care is to maximize the number of Americans who can afford to buy health insurance for themselves, instead of having to depend on the government or their employer,” Avik wrote in a Post op-ed. “The Senate bill transforms the American health insurance landscape in this direction.”

Avik tweeted this shortly after the bill was released last Thursday:

And from former Romney policy advisor Lanhee Chen:

HEALTH ON THE HILL

Sen. Dean Heller explains why he opposes the Senate GOP health-care bill:

–Now five Republican senators — one moderate and four conservatives — are saying they won’t support the Senate health-care bill without changes. Moderate Sen. Dean Heller (R-Nev.) became the fifth member joining the resistance when he expressed concerns about McConnell’s draft on Friday, my colleague Sean Sullivan reported.

Heller said he “cannot support a piece of legislation that takes away insurance from tens of millions of Americans and hundreds of thousands of Nevadans.” Three important factors to note here: Nevada expanded Medicaid under the ACA. Heller is up for reelection in 2018. And he’s the only Republican senator running for reelection in a state that went for Hillary Clinton last November. Heller’s statement doesn’t necessarily mean he’s ultimately going to vote against the Better Care Reconciliation Act, but it does mean McConnell would need to modify the legislation so as to give cover to Heller for supporting it.

Heller joins Sens. Ted Cruz of Texas, Rand Paul of Kentucky, Mike Lee of Utah and Ron Johnson of Wisconsin who are also opposing the bill in its current state. Those four have opposite concerns that it preserves too much of the ACA. This is a bad math equation for McConnell, who will not be able to pass the legislation if more than two Republicans defect. It sets up what my colleague Paul Kane calls a “final frenzy of negotiation.

–As McConnell scrambles to save the measure, he needs help from the Trump administration to win over the skeptical conservatives. At the same time, he is seeking a separate way of winning wary GOP moderates over whom Trump holds little political influence, such as Sens. Susan Collins (Maine) and Lisa Murkowski (Alaska.), who oppose the bill’s blockage of federal funding to Planned Parenthood, among other things.

“He’s looking at how to bridge a gap that seems to be insurmountable and try to find a way to get this,” Sen. Patrick J. Toomey (R-Pa.), a defender of the bill, told my colleagues Kelsey Snell, Sean Sullivan and Robert Costa last week.

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