For the rest of December, Washington Examiner reporters will be exploring what 2018 has in store in a number of areas, from the White House and Congress to energy and defense. See all of our year ahead stories here.
Congressional Republicans were unable to coalesce around a plan to replace Obamacare this year, and they are in a similar situation headed into 2018.
The struggle is between those who want to work to stabilize Obamacare in the face of rising premiums and insurer exits and others who would like to take another shot at a repeal or overhaul bill. The Senate was unable to reach a 50-vote threshold to pass an overhaul bill through reconciliation, and next year the Senate has a lower margin of error with only a 51-seat majority.
Senate Majority Leader Mitch McConnell has signaled that he prefers to focus on bills that are aimed at stabilizing the exchanges and reducing premiums, rather than on overhaul efforts.
"Well, we obviously were unable to completely repeal and replace with a 52-48 Senate,” he said recently in an NPR interview. “We'll have to take a look at what that looks like with a 51-49 Senate. But I think we'll probably move on to other issues."
Other statements he has made on healthcare mirror those of GOP Sens. Lisa Murkowski of Alaska and Susan Collins of Maine, who were opposed to overhaul bills and have recently said they would like to pursue a bipartisan healthcare fix.
“I think we need to just take a break and get through tax reform and try to find some issues or initiatives that we can come together on,” Murkowski, R-Alaska, told the Washington Examiner when asked about Republicans losing a Senate seat in Alabama.
Two bipartisan bills intended to stabilize Obamacare and lower premiums are likely to be considered early in the year. Collins received a guarantee from Republican leadership that the bills would come to the floor to help mitigate some of the effects of repealing the individual mandate that requires people to buy health insurance or pay a fine. The mandate's penalties were repealed by Congress as part of a larger piece of legislation that overhauled the tax code.
Collins had hoped that the Obamacare bills might pass before the end of the year, but in a joint statement with Sen. Lamar Alexander, she said it would need to happen early in 2018 to be bipartisan. Conservative House members are concerned with passing a bill they view as a “bailout” of Obamacare, and Democrats in the Senate told them they would “not support it in the current environment.”
“It looks like the Christmas present of lower health insurance premiums will now have to be a Valentine’s Day present,” Alexander said.
Collins has indicated that she believes the White House will help spur conservative House members to vote for the bill. The White House declined to comment on the extent to which the president made calls to House members about the bills but said it supported their passage and was “actively working with Congress to move those bills forward.”
Republicans in the Senate who support the stabilization package say a short-term solution is needed before trying again to overhaul Obamacare.
Sponsors of an Obamacare overhaul bill, including Sens. Lindsey Graham of South Carolina, Bill Cassidy of Louisiana, Dean Heller of Nevada and Ron Johnson of Wisconsin, hope that their plan might be considered again. The plan would transfer revenue from Obamacare to states.
Graham, in particular, said it was necessary for Republicans to revisit an overhaul rather than to move on, which they said “would be a mistake.”
“We will need House and Senate leaders on the Republican side as committed to repealing Obamacare as Nancy Pelosi and Harry Reid were to passing it,” he said.
Sen. John Thune, the third-ranking Republican, has said that Graham-Cassidy would be the likely avenue on healthcare, though he left the door open to other possibilities.
“My guess is that if we are able to move forward, if we can find 50 votes for something, it will probably be along the lines of a Graham-Cassidy approach,” he said. “That is something that most of our members found a lot of merit in and to be a fairly workable solution.”
“But again, when I say ‘a lot of our members,’ whether that’s 50 or not remains to be seen. But I know Lindsey and Bill Cassidy are still working it hard,” he continued.
The White House has supported Graham-Cassidy but has said it is open to alternative proposals.
Republicans also have indicated that they hope Democrats will be willing to work with them on healthcare in reaction to already damaged markets and repeal of the individual mandate penalties.
“It would be nice if there was a bipartisan approach because I think we would get a better long-term, more durable and lasting solution,” Thune said. “So I hope the Democrats will decide to play ball.”
Funding for health programs
Republicans also need to fund programs that will run out of money and cause people to become uninsured. After they return from winter break, Congress will have to figure out what to do about the Children’s Health Insurance Program after punting a multi-year reauthorization to the program and others, such as funding for community health centers, into early next year.
Republicans and Democrats disagree over how to fund the program. Republicans want to use an Obamacare prevention fund and charge higher Medicare premiums for wealthy seniors, which Democrats oppose.
Areas of possible agreement
Some areas are expected yield bipartisan support next year, with actions to tackle high drug prices likely among them.
There is growing momentum by both Republicans and Democrats to target a “gag rule” on pharmacists.
Pharmacy benefit managers, which oversee prescription drug plans for insurers, sometimes mandate to pharmacies in their contracts that the pharmacist can’t tell patients they can pay less for a prescription out of pocket. Several states have outlawed the measure, the latest being Connecticut in July.
“Sometimes pharmacists have gag orders that they can’t tell the patient it is cheaper to pay cash than go through your plan. That is crazy,” Cassidy said.
Other ideas to tackle drug prices include clamping down on “evergreening,” a system in which drug makers receive a new patent for a slight modification to a brand name product to extend its monopoly on sales. Both Republicans and Democrats have criticized the practice in recent weeks.
A second area for possible bipartisanship is how to address the opioid epidemic. In 2016, Congress passed the Comprehensive Addiction and Recovery Act that provided new tools on tackling the crisis. Congress also passed the 21st Century Cures Act, which included $1 billion in funding to fight the crisis.
Now talk will turn toward another round of funding to combat the epidemic that killed 115 Americans a day in 2016.
The White House has said it is looking into the overall cost of the epidemic, which could lead to further action in Congress to approve new funding. Democratic Sens. Jeanne Shaheen and Maggie Hassan of New Hampshire introduced a bill in October to invest $45 billion over a decade for prevention, detection and surveillance of opioids. New Hampshire has been one of the hardest hit by the crisis.
What to do about entitlements?
But a major question mark for health policy in 2018 is entitlement cuts, specifically cuts to Medicare. House Speaker Paul Ryan has hinted in several interviews that he wants to target entitlement programs such as Medicare and Medicaid, which he said in one radio interview are the biggest drivers of debt and the deficit.
However, he has since walked back those comments. He said last week that any action on Medicare next year would target providers.
“Some providers in the Medicare field are getting overpaid,” he said on ABC’s "Good Morning America." “As far as you talk about beneficiaries, we are not focused on that.”