Daily on Healthcare: Leadership charges ahead…GOP lacks votes…is McConnell bluffing?

Senate Majority Leader Mitch McConnell is charging ahead: He’s communicating that this week is do or die for passing a healthcare bill, even as they are currently short of the votes needed for passage. On Tuesday, Republican senators will meet for lunch to hash out their differences and discuss the path forward and Vice President Mike Pence will be in attendance – an indication of the high stakes.

Here’s what you need to know about what to expect this week:

The ticking clock: Once McConnell is ready to begin the process, under the expedited rules, he can bring the bill up for a vote on a motion to proceed. If he clears that hurdle, it triggers a period of 20 hours of debate. After that period, under the rules of reconciliation, senators have the ability to offer unlimited amendments, triggering what is called a “vote-a-rama.” This period is typically exploited by the opposition party as a way of eating up time and forcing the majority party to cast embarrassing votes. Doing the math, that means that Republicans would have to vote on the initial motion to proceed by Wednesday afternoon if they want to cast the final vote by Friday morning and get out of town for the July 4 weekend. Otherwise, votes will have to spill into the weekend.  

They don’t have the votes: The problem with holding a vote so soon, is that as of now, a vote on the bill in its current form would fail. At least six senators have come out opposed to the bill, and any combination of three senators can sink it. The six senators include four conservatives: Rand Paul, Mike Lee, Ted Cruz and Ron Johnson and two centrists: Susan Collins and Dean Heller. All of them but Cruz have come out and said they would vote against the initial motion to proceed in addition to the final bill.

Negotiations are ongoing: Senate leadership is still trying to work with key lawmakers on changes to the bill that could potentially win them over. Because the Congressional Budget Office on Monday scored the bill as reducing deficits by $321 billion (or $202 billion more than the House-passed bill), McConnell has some money to play with to woo moderates with more spending, such as additional money to fight opioid abuse. At the same time, they are trying to win over conservatives, and some ideas are being floated about expanding health savings accounts to allow for bigger contributions and additional flexibility, and creative ways to offer regulatory relief from Obamacare. Cruz has been pushing an idea that would allow insurers to offer non-compliant health plans in a state as long as they offer at least one plan that meets all of Obamacare’s regulatory requirements. So, the contents of the bill are still moving.

The bluff factor: While McConnell is giving every indication that this week is the deadline to pass a bill, a number of insiders speculate that there is an element of bluffing. Though he no doubt would want to get this vote finished as soon as possible, there is no statutory reason why a vote would have to come this week. Yet creating the appearance of a firm deadline is the best way to light a fire under lawmakers and force activity. That would be the savviest course for McConnell to pursue even if secretly his real internal deadline was to get a bill passed before the August recess.

Our wild speculation: If McConnell doesn’t have the votes, but thinks that with more time to negotiate, he can get there, then it makes sense that he would delay a vote and then work toward passing a bill by the recess. If he doesn’t have the votes and thinks that no amount of negotiations are going to bridge the gap between centrists and conservatives, then maybe he decides to cut his losses and stop wasting any more time on this healthcare bill. If that’s the case, then one could see how he would hold the vote this week win or lose, and then move on assuming it goes down in flames. We’d still bet on it spilling over into after the July 4 recess. 

Welcome to Philip Klein’s Daily on Healthcare, compiled by Washington Examiner Managing Editor Philip Klein (@philipaklein), Senior Healthcare Writer Kimberly Leonard (@LeonardKL) and Healthcare Reporter Robert King (@rking_19).  Email [email protected] for tips, suggestions, calendar items and anything else. If a friend sent this to you and you’d like to sign up, click here. If signing up doesn’t work, shoot us an email and we’ll add you to our list.

Anger at GOP leadership simmers among conservatives: Sen. Ron Johnson, R-Wis., didn’t mince words when reporters asked if leadership is hearing his concerns. “I would say no,” said Johnson, who is a no on the bill in its current form. Johnson, as you may recall, was a stalwart attendee of the biweekly healthcare working group that met for weeks on healthcare reform.

Suffice it to say, Johnson wasn’t happy with the group’s lack of input on the finished product.

Sen. Rand Paul, R-Ky., who didn’t attend the meetings but is spearheading the “gang of four“ opposing the bill, said he hasn’t heard from leadership. However, he has spoken with officials at the White House.

Paul to meet with Trump over lunch: Paul, a conservative who was elected to Congress during the Tea Party wave of 2010, has expressed concerns with the legislation, saying it doesn’t go far enough in repealing Obamacare. “Headed to meet with @realDonaldTrump this afternoon,” Paul tweeted. “The bill is currently not real repeal and needs major improvement.” He continued: “I’ll discuss w/ him how to fix bill & get more to a YES on real repeal, things I’ve tried to tell Senate leaders with no result so far.”

Paul suggests not passing any bill at all: Rand Paul is suggesting that it may be better to let it just die. “I think what we are gonna end up with is that it is worse to pass a bad bill than no bill,” he told reporters Monday. Paul’s reasoning is that people are going to find out that their premiums still rose “25 percent and Republicans said they fixed this.” The Kentucky Republican has complained the bill doesn’t do enough to lower premiums, a key criticism from other conservatives as well. “The death spiral of Obamacare will continue,” he said.

Other GOP senators express reservations, including Bill Cassidy of Louisiana. “It makes me more concerned,” he said shortly after the score was released. “I’ve been uncommitted — and I remain uncommitted, I mean just deadline uncommitted — but it certainly makes me more concerned, it makes me want to explore this more.”

Cassidy says Medicaid expansion isn’t sustainable: Louisiana Sen. Bill Cassidy said centrists have to come to terms with the future of the Medicaid expansion. “The expansion I don’t think is sustainable for states,” he told the Washington Examiner Monday. “It isn’t as if this is an idealized situation which this is going to last forever.” Cassidy was referring to how states are going to have to start paying more of their share of the expansion. By 2020, states will have to pay 10 percent of the Medicaid expansion costs. “It’s something where Californians can’t afford their 10 percent or Louisiana can’t afford their 10 percent,” said Cassidy, a key centrist vote who says he is still undecided on the bill. The Senate draft bill keeps the Medicaid expansion in place but starts to draw down federal funding over three years. It then converts federal funding to a fixed amount or a fixed amount per beneficiary. The CBO predicted that the Senate bill would result in more than $700 in Medicaid cuts over a decade.

Chuck Schumer predicts GOP ‘buyouts and bailouts’: The Senate minority leader is predicting that GOP dealmaking will be necessary for Republicans to secure the votes needed to pass their measure to partially repeal and replace Obamacare. “There will be buyouts and bailouts and tweaks that will be hailed as fixes on the other side,” he said. “But the truth is the Republicans cannot excise the rotten core at the center of this healthcare bill.” Democrats justified the closed-door dealmaking they employed in 2009 to pass Obamacare, which included provisions aimed at bringing on more moderate lawmakers in their party. Schumer said the difference is that the Democrats were crafting a deal to provide more people with healthcare, not fewer as with the GOP plan. 

White House focuses on CBO’s off-target Obamacare projections: “The CBO has consistently proven it cannot accurately predict how healthcare legislation will impact insurance coverage,” the White House said in a statement following the release of the latest CBO score. “This history of inaccuracy, as demonstrated by its flawed report on coverage, premiums and predicted deficit arising out of Obamacare, reminds us that its analysis must not be trusted blindly.”

Still, the White House is leaving most of the work to Senate Republicans, particularly compared to its involvement with the House bill. “Sink or swim, this bill rests on the shoulders of leadership,” one GOP Senate aide told the Washington Examiner. “It is their product with minimal White House involvement.” Privately, the president and his team have left much of the heavy lifting to McConnell, who faces the challenge of changing the legislation to satisfy some or all of the Republican senators who oppose it as it is written. Trump picked up the phone during the weekend to call four Republican senators who have expressed concerns about the healthcare plan: Ted Cruz of Texas, Rand Paul of Kentucky, Shelley Moore Capito of West Virginia and Ron Johnson of Wisconsin. On Friday, Vice President Mike Pence called Sen. Dean Heller after the Nevada Republican came out strongly against the bill, a White House aide told the Washington Examiner.

Pence will be back on Capitol Hill Tuesday for the weekly Senate Republican lunch, where he likely will discuss the perilous path forward for the Obamacare reform bill. “He’ll have a few meetings with individual lawmakers while he’s on the Hill,” said an aide to the vice president. “He continues to take calls, and he’ll have meetings.” Later Tuesday evening, Pence has invited a handful of Republican senators — including Utah Sen. Mike Lee, who opposes the bill in its current form — to a dinner at his home, the Washington Examiner confirmed. 

House Speaker Paul Ryan believes Republicans will be vindicated on healthcare. The Wisconsin Republican said he believes Americans are rejecting the Democrats’ knee-jerk opposition to Trump and boldly predicted that Americans would reward Republicans in 2018 for following through on a healthcare agenda that, for now, is deeply unpopular. “The Democrats are in disarray. All they’re doing is suggesting they’re going to come and fight and resist, and I don’t think that’s what voters want,” the Washington Examiner. “We just saw four victories for tackling problems and addressing issues, and four defeats for just simple resistance — and that was the basis of their campaign,” he added, referring to GOP special election wins.

Ryan also addressed CBO score, arguing the uninsured number could was bad news. “What they’re basically saying at the Congressional Budget Office is if you’re not going to force people to buy Obamacare, if you’re not going to force them to buy something that they don’t want, then they won’t buy it,” Ryan told “Fox News” in an interview taped just as CBO released its report Monday evening. “So it’s not that that people are getting pushed off our plan. It’s that people will choose not to buy something they don’t like or want. And that’s the difference here,” Ryan added. “So by repealing the individual and employer mandate which mandates people buy this health insurance that they can’t afford and don’t like, if you don’t mandate that they’re going to do this, then that many people won’t do it.”

Flashback to Obamacare’s passage … Back in 2009 and 2010, as President Obama and the Democrats in Congress were closing in on final passage the extremely unpopular Affordable Care Act, they vowed that Americans would embrace Obamacare once it was implemented and they experienced the benefits. It never happened, and Democrats paid a heavy price in dozens and dozens of lost seats in consecutive midterm elections. Until, that is, this year, when the Republicans’ plans to replace the law got rolling.

Former Attorney General Eric Holder blasts Senate Republican healthcare bill. “McConnell/@realDonaldTrump: who do you stand with on health care?” Holder tweeted Monday night. “The average guy or the wealthy? You’re taking care away from millions-why?”

Trump group’s attack on Heller could backfire. Heller is running for re-election in a battleground state that voted for Democrat Hillary Clinton in November — and his popular Republican governor, Brian Sandoval, opposes the Better Care Reconciliation Act.

If Heller comes around, even after negotiating changes to the bill, he risks charges of capitulating under pressure from Trump, even if America First Policies never follows through with its promised seven-figure advertising buy in Nevada. That could create additional obstacles for his 2018 campaign, and McConnell’s effort to cajole 50 votes out of his 52-member conference. “What the Trump group has done makes it even harder for Heller, because now if he’s a ‘yes,’ he’s not a yes on the substance, but on the politics,” a Republican insider told the Washington Examiner, on condition of anonymity to speak candidly. Brian O. Walsh, president of America First Policies, the officially sanctioned Trump outside group, declined to address questions about the group’s strategy. “Heller needs to get to ‘yes,'” is all he would say. The group said separately that its campaign against Heller was full steam ahead.

Pro-Obamacare group hits Murkowski with ad: The pro-Obamacare Group Save My Care is targeting one of the most reluctant centrists to vote against the Senate healthcare reform bill.

Save My Care is airing new TV, radio and digital ads in Alaska to help persuade Sen. Lisa Murkowski, R-Alaska, to “put Alaskans first and vote against the GOP repeal bill.” The ad points to Murkowski’s prior remarks that she won’t “support a reckless repeal process that leaves people hanging.” Murkowski has yet to announce her position on the healthcare bill. She has previously had concerns about the impact of Medicaid cuts and the defunding of Planned Parenthood for one year under the bill.

Uh oh: Liberal group flies plane over West Virginia with banner targeting Heller. The banner that flew behind a plane above Charleston read: “Sen. Heller Keep Your Word: Vote No on Trumpcare.” The banner, a protest from the feminist group UltraViolet, had actually been intended for West Virginia Sen. Shelley Moore Capito.  

Governors ask McConnell to give states time to review healthcare bill. “As chief executives of our states, we have an obligation to protect the health and welfare of our citizens. The nation’s governors are ready to work with leaders in Washington to make healthcare more accessible and affordable to the people we serve,” Virginia Gov. Terry McAuliffe, the National Governors Association’s chairman, and Massachusetts Gov. Charlie Baker, vice chairman of the NGA’s health and human services committee, wrote in a letter to McConnell. “However, governors must be given adequate time to determine the impact any healthcare bill will have on their states and residents, and ensure that the bill does not adversely harm the people we were elected to serve,” McAuliffe, a Democrat, and Baker, a Republican, continued.

Industry groups opposed to the Senate bill: American Medical Association, American Psychiatric Association, American Public Health Association, American Hospital Association, America’s Essential Hospitals, American Osteopathic Association, American Heart Association, American Cancer Society Cancer Action Network, American Lung Association and March of Dimes.

Not everyone is opposed: The U.S. Chamber of Commerce released a key vote Tuesday in support of the Republican healthcare proposal, backing its repeal of the mandates and many of the taxes in Obamacare. It also pointed the the flexibility and funding it said the bill allows states in crafting their own healthcare proposals. “While the Chamber recognizes that further improvements can — and must — be made, passage of this legislation is vital to restoring choice, flexibility and innovation to America’s health care markets and growth to our economy,” Jack Howard, senior vice president of congressional and public affairs for the Chamber, wrote in the letter. The Chamber also signed a coalition letter of support with 27 other organizations, including the Council of Insurance Agents and Brokers, the National Association of Home Builders and the National Restaurant Association.

Anthem and the Blue Cross Blue Shield Association support parts of GOP healthcare bill. The support is based on the bill providing an initial stability fund for insurers that sell plans on the Obamacare exchanges as well its repeal of the health insurance tax. “Based on our review, we believe the Senate discussion draft will markedly improve the stability of the individual market and moderate premium increases through substantial stability funding, appropriating cost-sharing reduction funds, aligning premium subsidies with premium costs, and eliminating the health insurance tax which alone would result in a 3 to 5 percent premium decrease for our fully insured members,” the company said. The statement did not include comments on the newest provision of the bill, which would add a six-month wait period for coverage if people let their insurance lapse. Blue Cross Blue Shield Association said the bill contained “strong incentives for people to stay covered continuously.” The association supported the stabilization measures as well. Both said they wanted to work toward improvements on the Medicaid provisions.

Washington state has filled its empty counties. “After several weeks of discussions, I am pleased that two insurers have stepped up to offer insurance in Klickitat County next year,” Washington’s insurance commissioner, Mike Kreidler, said in a statement. Molina Healthcare of Washington and BridgeSpan Health Co. will offer plans on the state’s exchange, called Washington Healthplanfinder. Kriedler previously worked to fill another empty county, Grays Harbor, that was facing the prospect of having no insurers on the exchange.

RUNDOWN

Axios What’s next if healthcare bill fails?

The Hill Former GOP senator: Let Democrats engage on health bill

STAT News The game changers: 12 bold attempts to slow the opioid epidemic

Kaiser Health News House seeks to cap medical malpractice awards as part of healthcare reform

Politico Republicans eye billions in side deals to win Obamacare repeal votes

Washington Post The 5 factions that could kill Senate Republicans’ healthcare bill before it gets to a vote

CBS News Does health insurance save lives?

Health Affairs The downstream consequences of per capita spending in Medicaid

Calendar

TUESDAY | JUNE 27

12:30 p.m. 111 Michigan Ave. NW Children’s National Medical Center. House Minority Leader Nancy Pelosi and other Democratic members of Congress will meet with patients and their families, and speak about the effects of the GOP healthcare bill.

1 p.m. Capitol Hill steps. Senate Democratic Caucus press conference on the GOP’s healthcare bill.  

2 p.m. Capitol grounds by the Supreme Court. Planned Parenthood to speak out on GOP healthcare bill.

2 p.m. 2103 Rayburn. Law enforcement and national marijuana policy group host Capitol Hill briefings on marijuana black market.

6:30 p.m. Newseum. 555 Pennsylvania Ave. NW. Documentary showing of “Written Off,” about the opioid crisis. Trailer.
 

WEDNESDAY | JUNE 28

10 a.m. Bipartisan Policy Center. 1225 I St. NW. Event on “Cybersecurity and Medical Devices.” Details.

Noon. Urban Institute. 2100 M St. NW. Event on “Stabilizing the Individual Health Insurance Market.” Details.

Noon. 2044 Rayburn. Cato Institute event on “A ‘Modern Plague?’ How the Federal Government Should Address the Opioid Crisis. Details.
 

Noon. 2167 Rayburn. Capitol Hill briefing on “What’s the Right Decision for Me? Shared Decision Making in Prostate Cancer,” hosted by the Patient-Centered Outcomes Research Institute (PCORI) and the Men’s Health Network.

THURSDAY | JUNE 29

10 a.m. Bipartisan Policy Center. 1225 I St. NW. Event on “Future of Healthcare: Balancing Coverage and Cost in Medicaid.” Details.

10:30 a.m. American Enterprise Institute. 1789 Massachusetts Ave. NW. Event on “Sensible Regulation of E-Cigarettes: Opportunities for Reform.” Details.

4 p.m. American Enterprise Institute. 1789 Massachusetts Ave. NW. Event on “The Role of Government in Medical Innovation. Details.

6 p.m. 101 Constitution Ave. NW. Independent Women’s Forum event on “Oops! Sorry We Were Wrong … How Public Health Guidance Often Harms the American Public.” Details.

FRIDAY | JUNE 30

June 30-July 3. Marriott Marquis San Diego Arena. San Diego. Annual conference for the National Association of School Nurses. Details.