Should the GOP repeal and replace the Affordable Care Act now? Repeal now and replace later? Or let the law sputter and die?
President Donald Trump and Republican leaders have lots of ideas but seemingly no coherent plan they can all get behind, at least not yet. It appears increasingly doubtful that the Senate can muster the votes to torpedo Obamacare. In the meantime, some in the Trump administration seem intent on undermining the law.
That leaves much uncertainty, especially in states like California that have fully invested in Obamacare and have so much riding on whether it survives. This week, the state’s exchange scrapped plans to release 2018 premium rates, flummoxed by the many unknowns.
In this podcast, Julie Rovner of Kaiser Health News, Stephanie Armour of The Wall Street Journal, Sarah Kliff of Vox.com and Margot Sanger-Katz of The New York Times discuss the GOP’s ever-changing strategy vis-a-vis the health law they have been trying to kill for seven years.
This transcript has been condensed and edited for clarity.
Julie Rovner: So, it’s been quite a week, and the week isn’t even quite over yet. The Senate health bill first got delayed over the weekend due to [a] surgery that sidelined Sen. John McCain back home in Arizona. Now we’ve learned that the senator has brain cancer. We all send him our good wishes … but it’s not at all clear when he will be back. Then the health bill appeared to die on Monday night when two conservative senators, Mike Lee of Utah and Jerry Moran of Kansas, said they wouldn’t vote for it. That brought the total to four [Republicans opposed], which [leaves] not enough [votes] to even start debate. But like the zombie bill this has been, it came back to life … on Wednesday when President Trump had all the senators to the White House for lunch and insisted that they somehow keep their promise to make Obamacare go away. So now Senate Majority Leader Mitch McConnell, who’s in charge of what one senator colorfully described as trying to keep all the frogs in a wheelbarrow, has scheduled a vote for next week, but it’s not entirely clear on what. So, Stephanie, where are we?
Stephanie Armour: The bill basically, as far as I can tell, seems to be back. … It’s kind of the Senate health bill 3.0. It is a desire to return to the Senate health bill that initially did not have enough votes to move forward. There is obviously a push to do a full repeal, but the general thinking from the folks I’m talking to is that that will likely fail, but that sets the stage or that opens the window to return back to the Senate health bill [Better Care Reconciliation Act]. But, at this point, there are discussions underway to try to get those holdout people back on board, and some of that could result in tweaks to the Senate health bill.
Rovner: We should probably have names for all these — Senate health bill 3.0 is actually the repeal-and-delay bill that passed in 2015. Right?
Armour: [BCRA] seems to be what is gaining the most momentum. … You saw the [Congressional Budget Office] score that came out yesterday on the full repeal and what that would do, and I think that’s going to be really hard to get moderates to support.
Margot Sanger-Katz: I think part of the reason this is so confusing is that the president has had three positions in 24 hours about what he wants to do. … And he just tweets his views out into the world, and so it’s really clear to see how his thinking has evolved. But, you know, over the course of just a couple of hours he said: Let’s just let Obamacare fail and we’ll take it from there. He said: What we need is a full repeal and we’ll deal with the ‘replace’ part later. And then he said: Let’s get back on this original comprehensive Senate bill. So it seems sort of like all strategies are being pursued at once.
Rovner: But, Sarah, I want to go back to the repeal-and-delay [proposal] because that was what they did in 2015 and it seemed to — briefly, at least — come back to life.
Sarah Kliff: It had this moment of resurgence. I think all of us remember back in January when Senate Republicans considered ‘repeal and delay.’ … You pass a bill that repeals Obamacare and delays the effects until two years later. So, presumably, in the interim they would come up with a plan to replace it. … It kind of assumes there is some plan out there, although that is a somewhat shaky assumption at this point. … It’s quite hard for Republicans to agree on a plan, of course. …
… So there’s a bit of magical thinking that once you get rid of Obamacare, the Democrats will just be forced to come to the table, and they’ll work on this plan.
I don’t really see that from the Democrats I talk to. They kind of have this, you know, “You break it, you buy it. We’re not getting you out of the mess.” In either case, we had a CBO report come out … that estimated 32 million people will lose coverage under repeal and delay if the replacement ever came. But what I thought was actually the most interesting number in that report was the fact that 17 million will lose coverage the first year of repeal and delay. So repeal and delay feels like a bit of a misnomer. … The effects would be quite immediate, the CBO estimates, because the individual mandate disappears in the first year.
Sanger-Katz: Yes, but … if you read what CBO says, it’s not just the individual mandate. So the individual mandate results in some people losing coverage. … The whole theory of repeal and delay is that you would basically have everything just coast along status quo until all of a sudden everything falls off a cliff. But the very thing that would be the motivation for there to be a political compromise, which is the recognition that the cliff is coming, of course influences the behavior of people in the meantime. So insurance companies don’t want to make these big investments in this market if there is not going to be a market in the future. And I think a lot of consumers, also, once they hear that Obamacare has been repealed, even if there is this … time delay on it, probably would be less likely to sign up. And so what CBO said is that a lot of insurance companies are just going to say, “No thank you, I don’t want to participate in this zombie market in the meantime.”
Armour: And don’t forget that we’re talking about all these people losing coverage right before the 2018 midterm elections. And that’s got to weigh heavily on the minds of Republicans.
Rovner: I guess that’s what the meeting last night in the Senate was about, this closed-door meeting that [was], you know, trying to get people to yes. But people seem to need diametrically opposed things to get to yes.
Armour: Anything you do to move it to appease individuals like [Sen.] Mike Lee or some of the conservatives, you’re going to lose the moderates even more. And at this point, the big thing for [Senate Majority Leader Mitch] McConnell is he needs to try to get enough votes for at least a motion to proceed … because once it’s on the floor, anything can happen. Amendments can happen. But it’s still not clear how he’s going to get those votes.
Sanger-Katz: It’s a really interesting strategy to me, because it seems to be predicated on the idea that if they can just open debate there’ll be some momentum and it will be politically harder for senators to vote against whatever the final product is … [and] there will be opportunities for them to bring forward amendments that they want and have them considered. And, you know, maybe feel like they’ve at least tried to do what they want to do to the bill. But the downsides seem pretty substantial, too, because the special budget reconciliation process that they’re using, there is just like an open-season amendment process where an unlimited number of amendments brought by both Democrats and Republicans can be raised and voted on. … And if that process does not end in the bill succeeding … it seems like kind of a costly process.
Rovner: Which brings me sort of to the big question here: Is this bill dead or not?
Armour: I do not think it’s dead. I think that the individuals who are opposed to any kind of repeal are very concerned about what could happen. They’re very concerned that certain senators — [Ohio] Sen. [Rob] Portman and some others, [Nevada] Sen. [Dean] Heller — are kind of wavering. … But frankly, I think it is very, very much a long shot as to whether they’re going to get there. And I also think that the risk quite frankly [is] not only pushing off so much of the agenda they need to get to but at a certain point dragging out this process. I also think it starts to look bad for President Trump and the Republicans.
Sanger-Katz: I’m just trying to count votes and I don’t think they have got them. I don’t think that there are enough votes for either of these proposals that are on the table or for some sort of minor modifications, and I do think that Sen. McCain’s illness makes that math even more difficult for them. You know, of course it’s possible that he would come back to vote on this, but it sounds like probably he’s undergoing some kind of treatment and rightly prioritizing his health over this bill. … I just don’t know how they get it over the line.
Kliff: I think the bill is alive in the sense that it is still dominating the news, dominating Republicans’ attention. You know that it’s sucking up the energy. … It’s very much alive in terms of being the main policy focus. But … like Margot was saying, it’s very, very hard to see how the votes come together. So it’s kind of a terrible situation for Senate Republicans, where this thing that it doesn’t seem like they can pass is still sucking up all the energy and attention and debate and they’re not moving on. They’re kind of stuck on this thing that they can’t move forward.
Rovner: I mean there was this rumor that’s been going on for months now that Sen. McConnell would bring a bill to the floor to fail, which is just so unusual. … But in this case he almost needs to prove to the president that they did everything they could and couldn’t do it. Do you think that’s what’s going on here?
Sanger-Katz: I think it’s pretty clear that the president wants people on the record and has throughout this whole process. If you remember, the first time that the House bill came up for a vote, the House whips did not have the votes. And the reason why they voted is because the president insisted, “No, no, no, go on the floor, put people on the record, they’re going to have to vote for it or I’m going to know who didn’t.” And you know [House Speaker Paul] Ryan went to the White House, it seemed sort of at the eleventh hour and said, “This is going to be really embarrassing.”… And they pulled it off the floor.
Rovner: So I want to talk about President Trump. … I think he’s had, shall we say, a unique role in this entire saga that’s consumed the last seven months of all of our lives. Has he helped this in any way or has he hurt it?
Kliff: I don’t think he’s helping it. And it’s really, I think, [for] a lot of … us who covered President Obama in his push for health care … it feels pretty night and day … listening to the two presidents talk about health policy. … It was pretty clear that [Obama] had a good grasp of health policy and [an] understanding of insurance markets and of health care costs. And you don’t really see that with President Trump. There was an interview he did yesterday with some of Margot’s colleagues at the Times where he estimated that health insurance ought to cost $12 a year which, you know, when I interview Obamacare enrollees, and I ask them how much health insurance should cost. They don’t say $12 a year they say 50 or 100 bucks a month because they understand what the insurance market is like. They have, like, a reasonable kind of ballpark. … Elsewhere in the interview, he says, “I know health care really well,” but most of his public statements about it really suggest that there isn’t a good grasp, and that makes it very, very hard for him to make the case to someone like [Maine] Sen. [Susan] Collins of why this bill should pass.
Sanger-Katz: But I think hindsight will be 20/20 here, so I think now that we all think that the bill’s chances are very poor, I think it’s easy to say that President Trump’s involvement has been unhelpful, but I do think that one thing he’s done throughout this process is really push members of Congress and the congressional leadership to keep trying even after they think that they can’t do it. …
… I think we’ve seen a similar dynamic this week in which it would seem clear that the Senate didn’t have the votes and it seemed like they were going to just kind of quickly dispatch with this and move on, and it was President Trump who said, “No, I want to have all of these senators over for dinner, it’s really important that we not betray our promise to repeal Obamacare.” Now if it fails in the end, none of that will have mattered, and I think it is certainly true that he does not have a great grasp of health policy and that he is not negotiating with these senators on the fine points, but I do think his persistence may turn out to be an important variable, if this does, in fact, succeed.
Armour: And I also think you see a change … like he really was fairly hands-off in terms of the process in the Senate so far, and that has really changed after it was clear they didn’t have the votes. And what was kind of remarkable about the meeting that he had yesterday was that he clearly … was stronger on some of the policy details. He spoke specifically to senators and he was sort of using what he’s known for, in terms of his “Art of the Deal,” of really putting some pressure on. And I think that the holdouts really realized that there could be candidates that are run against them in the primaries, and that puts a lot of pressure on them, and I think that there’s been a shift in his tactic. … How that will play out, I don’t know. I think that senators don’t like to be called out necessarily like that. So I do think you’ve seen some steps that have kind of really hurt the process. But I do think the verdict’s out on what’s happening right now.
Rovner: Assuming it goes down and there’s no bill, what happens next to the Affordable Care Act?
Kliff: I think all of us have been watching the marketplaces pretty closely and that you kind of see a struggle for some of those to stay afloat. I did a bit of reporting yesterday talking to experts who follow them who have run the marketplaces historically. They’re a little bit mixed on how badly 2018 could go, but they certainly expect maybe some counties won’t have insurance plans. … Nevada, for example, is struggling right now.
Rovner: I mean, literally, there’s like 500 people in some of these counties. But what about states that are running their own exchanges, [like] California?
Kliff: Yeah, I mean California seems pretty solid. I think states that want to make Obamacare work are generally finding ways to make it work. Washington state was instructive, for example. They had two counties with no health plans and the regulator … went out, knocked on some doors … really wanted those places to have plans, and now the whole state is covered. So you might see a bit of a disparity between states that want to make the Affordable Care Act work and go the extra mile and states that have taken more of a hands-off approach, where the insurance regulator is quite critical of the Affordable Care Act. They might have a very different experience next year.
Armour: But I think it also comes down to what happens with the cost-sharing subsidies, the payments to insurers. I think that’s being closely watched. … The administration right now pays billions of dollars to insurance companies to help offset the cost of these subsidies that go to low-income consumers to help them pay their out-of-pocket costs. So this is in addition to the premium help they get. … The question is, will those continue if the bill fails, or will President Trump just decide to end those payments unilaterally? And I also think if the bill fails, you will see some growing talk about some kind of bipartisan stabilization legislation.
Sanger-Katz: I think the Trump administration has some pretty big decisions before it. If this legislative effort fails, they have been pretty unfailing in their criticism of the law in their efforts to not help the parts of the law that need help, and perhaps to even undermine some of the parts of the law that don’t need to be undermined. And you know, we see Secretary Price, for example, is putting out tweets and statements and videos all the time that are criticizing the law and saying that it has all these problems. We’ve seen the Centers for Medicare & Medicaid Services publicizing lists of counties that don’t have insurers and in a kind of enthusiastic way. Like “look at how things are failing,” and we saw President Trump both in a tweet and in public statements to reporters this week say that his plan, if this legislative effort fails, is just to let Obamacare fail and then that will bring the Democrats to the table. And I think that there is an argument that making Obamacare look as bad and as troubled as possible is maybe a good incentive during a live congressional negotiation to try to bring your people to the table.
Kliff: A really good point Margot makes [is that] President Trump often talks about Obamacare failures as this set moment on the horizon. And I think it’s actually more accurate to think of it as the result of a lot of policy decisions [that will] be made in one way or another. The Affordable Care Act doesn’t really run on autopilot. It relies a lot on what the administration does to manage it. And you can manage it in a way that encourages health insurance companies to participate. You can manage it in a way that discourages them.
Rovner: The decisions they’ve made so far are actively working to undermine it. So I think just this week they’ve canceled the money for the navigators. … These are the people who help people work through the enrollment process, which is pretty complicated.
Armour: Yeah, yeah. And they have done some steps to help shore up the markets, especially for what insurers wanted in the short term. And I really think there’s been a desire to try to keep things floating along until there could be some kind of repeal or replace. But at this point, I don’t see any signs that the Trump administration would work or take significant steps to try and help the ACA markets if that legislation fails. That could change, but I think that would be such a major about-face … that it’s just hard to see. I think you’ll see a lot of waivers that will be encouraged and pursued that will allow states to do more things … to roll back parts of the ACA or to really impose new requirements on Medicaid.