Daily on Healthcare: Democrats threaten to bail on bipartisan Obamacare deal if GOP passes individual mandate repeal…Early Obamacare enrollment surges

‘The Producers’ effect? Nearly 1.5 million people signed up for Obamacare in first 12 days. Last week, we wrote about the potential for ‘The Producers’ effect to actually boost Obamacare enrollment this year, even as Democrats charge that Trump is trying to sabotage the program. During the first 12 days of Obamacare’s open enrollment, nearly 1.5 million people signed up for health insurance coverage through the federal healthcare.gov website, according to data from the Centers for Medicare and Medicaid Services. In November 2016, about 1 million people signed up for coverage over 12 days, which means the current pace of sign-ups is faster than under the last year of the Obama administration. Enrollment is stronger than many believed it would be. The second week resulted in 876,788 people signing up for plans, while the first four days resulted in 601,462 sign-ups. Within the total sign-ups up to this point, 1.13 million  customers were renewing customers who already have a plan through the exchange and 345,719 are new customers. The evaluation includes sign-ups only on healthcare.gov, which 39 states use, and does not have information about the other states that run their own exchanges.

Stop saying 13 million people will lose coverage if the individual mandate is repealed. Now that Senate Republicans have formally decided to add repeal of Obamacare’s individual mandate penalties to the tax bill, we’re going to be hearing a lot more about the Congressional Budget Office’s estimate that 13 million more Americans would be uninsured. But it’s important to keep in mind that this doesn’t mean that 13 million will lose coverage. The 13 million cited by the CBO fit into several different categories. Among them are 5 million Medicaid beneficiaries and 2 million workers who would decline offers of employer coverage. Because repealing mandate penalties would not change Medicaid eligibility, meaning that anybody who didn’t sign up would still qualify, and could be signed up if they ever needed medical care. Similarly, repealing the mandate penalties would not mean that those employees would lose their offer of coverage. So, right off the bat, at least 7 million of the 13 million would not really be losing any coverage. CBO also estimates that 5 million more would be uninsured in the individual market. While some of those would be priced out of insurance because premiums would increase, many would simply be healthy and choose to go without insurance. (The numbers don’t add up to 13 million because of rounding). What’s clear is that we can’t lump in all the 13 million together. Those who are priced out of the market due to a premium hike resulting from the individual mandate penalties being repealed are in a different boat from those who could sign up for Medicaid whenever they want.

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.

Paul Ryan: Individual mandate repeal up to Senate. The ability of Congress to repeal Obamacare’s individual mandate penalties will hinge on whether the Senate can pull it off, House Speaker Paul Ryan said Wednesday. “It really is whether or not the Senate has the votes for this or not,” the Wisconsin Republican said Wednesday on CNBC. If the upper chamber can repeal the individual mandate penalties, “we’ll meet them in conference and assess at that time,” Ryan added, noting that his chamber has voted several times to undo the mandate.

The inclusion could make the bill harder to pass on the House side, Republicans said. House Republicans told the Washington Examiner that many of their rank-and-file do not want to mix tax reform with a repeal of the Obamacare mandate because it does not include a provision to replace it. “I think we’d lose votes by putting it in,” Rep. Mike Simpson, R-Idaho, said. Republicans said the the savings their constituents would get from tax reform would be lost to increases in health insurance premiums. “It’s not the right thing to do,” Simpson said. “Because it doesn’t have a replacement. It’s a tough vote, no doubt about it.” The mandate repeal would bring in more opposition, some lawmakers warned. “There are a lot of our members who would like to do it, but there are some that don’t want to conflate healthcare and taxes,” Rep. Tom Cole, R-Okla., said. “I think the attitude here is let’s see what the Senate does. And it would obviously be an open topic in conference.” The House Rules Committee is not expected to add the mandate repeal. That’s a relief to most GOP lawmakers.

Senate Finance resumes markup with partisan acrimony. The GOP’s decision to include zeroing out penalties for the individual mandate in its tax reform legislation led to rare fireworks at the Senate Finance Committee as it resumed the tax bill markup Wednesday. “I am getting a little tired of being interrupted all the time and you calling on people and so forth,” said Committee Chairman Sen. Orrin Hatch, R-Utah. The remarks came after Sen. Ron Wyden of Oregon, the top Democrat on the panel, asked if Thomas Barthold, chief of staff for the Joint Committee on Taxation, had the same expertise as the nonpartisan Congressional Budget Office to remark on the impact on premiums and healthcare coverage. Wyden asked Hatch to bring in the CBO to the hearing, but Hatch refused since the individual mandate is a tax. Sen. Bill Nelson, D-Fla., chided Hatch for cutting off Wyden and his question. “It’s not your nature to cut off discussion. It’s not your nature to cut off a legitimate question,” he said. Hatch eventually relented and let Wyden ask the question. Hatch was not pleased healthcare was becoming a big part of the tax reform markup. “If we continually end up in the weeds on healthcare policy throughout the day, I will have to cut this part short,” Hatch said before starting a question-and-answer period on the new version of the bill.

A similar situation plays out in HELP Committee hearing. During a Senate Health, Education, Labor and Pensions Committee hearing Wednesday morning meant to be about how to create healthier communities, Murray began her introductory remarks by slamming Republicans for saying they would repeal the individual mandate then take up Alexander-Murray, calling advancing both measures “nothing more than political cover.” “First — let’s be clear about the policy: Tacking Alexander-Murray onto the partisan Republican tax reform effort is like trying to put out a fire with penicillin. It will not do anything to help,” she said. Murray lamented the partisan approach Republicans chose.  “The way that this was done, by sneaking devastating healthcare changes into a partisan bill at the last minute, is completely counter to the bipartisan spirit in which we worked on our stabilization bill,” she said. “Many of us agreed in the wake of partisan repeal efforts earlier this year that jamming partisan policy through before anyone has a chance to see it is absolutely not the right way to get things done, and it’s especially disappointing to see this happen because in working on our bill and reaching agreement, we proved we can work under regular order and find common ground.” Committee Chairman Lamar Alexander responded by saying that the tax bill was dealt with in the Senate Finance Committee and not by the HELP Committee. “It’s in a different bill in a different committee,” he said. “It’s in the tax reform bill … it’ll be considered separately and must be considered separately.”  Murray retorted that their bipartisan discussions did not include how they would tackle handling potential repeal of the individual mandate penalty. “We did not have hearings, we did not have input, we did not have any discussion about what the marketplace would look like if the individual mandate was repealed,” she said.

Republicans on the House side balk at stabilization deal. Several House Republicans on Tuesday said they oppose bipartisan legislation in the Senate to stabilize Obamacare in return for repealing the law’s individual mandate. House Speaker Paul Ryan, R-Wis., has opposed Alexander-Murray. “I don’t see that as something we are gonna take up right now,” said Rep. Mark Walker, R-N.C., chairman of the 170-member Republican Study Committee. Conservative Republicans and Trump have labeled the insurer payments that the deal would fund for two years as “bailouts.” “Alexander-Murray is toxic. Congress should not subsidize health insurance companies,” tweeted Rep. Warren Davidson, R-Ohio. Rep. Joe Barton, R-Texas, added that he supports repealing the mandate but not the subsidies. But he said he would wait to see the final Senate tax reform package before making a final decision. Other Republicans said that coupling the repeal of the individual mandate with Alexander-Murray would help them give the legislation a second look. “It would make me think more positively in that direction,” said Rep. Phil Roe, R-Tenn. “Obviously there is some cost to the cost-sharing arrangement, but I would take a look at that.”  

Insurers, providers warn of ‘serious consequences’ if Congress repeals the individual mandate. Lobbyists representing medical providers and health insurance companies are urging congressional leaders not to repeal Obamacare’s individual mandate without a replacement. “We join together to urge Congress to maintain the individual mandate,” the groups, representing doctors, hospitals and insurer wrote in a letter. “There will be serious consequences if Congress simply repeals the mandate while leaving the insurance reforms in place: millions more will be uninsured or face higher premiums, challenging their ability to access the care they need.” One of the groups that wrote the letter, America’s Health Insurance Plans, previously has supported a waiting period for people who don’t sign up for coverage during open enrollment. “Repealing the individual mandate without a workable alternative will reduce enrollment, further destabilizing an already fragile individual and small group health insurance market on which more than 10 million Americans rely,” they wrote.

Democrats spin GOP’s Obamacare strategy as an attack on middle class. Democrats on Tuesday found a new way to argue that the GOP tax bill will hurt the middle class when Republicans announced their legislation would eliminate Obamacare’s individual mandate penalty. Republicans said the penalty is hurting lower-income earners who cannot afford the rising price of insurance premiums and are then forced to pay what the Supreme Court has said is an Obamacare “tax.” But Democrats are spinning it as an attack on the middle class because of predictions that reducing the impact of the mandate by getting rid of the mandate penalty will lead to even higher premiums. “Tens of millions of middle-class families will pay higher taxes under the GOP tax scam, and now Republicans want to force them to pay higher health premiums too,” said House Minority Leader Nancy Pelosi, D-Calif. “Republicans’ addiction to repealing the Affordable Care Act and raising Americans’ health costs makes a terrible tax bill downright deadly.”

Poll: Public favors repealing the individual mandate, but shifts when faced with specific arguments. A Kaiser Family Foundation poll found that 56 percent of respondents support eliminating the individual mandate as part of a tax bill, while 42 percent oppose it. Their views changed when questions noted that most Americans aren’t affected by the individual mandate because they get coverage through a job or through a government program. When presented with that information, as many as 62 percent opposed the repeal. When presented with Congressional Budget Office estimates on the impact of repeal, the opposition rose to similar majorities. Further, Americans rank children’s health insurance funding ahead of stabilizing Obamacare, with 62 percent of respondents favoring that approach over 48 percent of respondents. Twenty-nine percent of respondents said that they believed repealing Obamacare was a top priority.

Bipartisan House bill reverses cut to drug program. A bipartisan bill would reverse a rule from the Trump administration that would cut $1.6 billion for drugs purchased by certain hospitals. The Centers for Medicare and Medicaid Services released a rule this month to cut $1.6 billion in reimbursements to safety net hospitals covered under the 340B program that requires drug makers to offer discounts for certain drugs. The legislation sponsored by Reps. David McKinley, R-W.Va., and Mike Thompson, D-Calif., comes after major hospital groups filed a lawsuit to prevent the rule from going into effect.

Democrats press for answers on NIH funding for gun violence research. Two senior House Democrats on Tuesday asked the National Institutes of Health to confirm whether it had discontinued funding for gun research after Trump was inaugurated. “We write to express concern about recent press reports that the National Institutes of Health has discontinued the dedicated funding program for gun violence research,” wrote Reps. Frank Pallone Jr. of New Jersey and Bobby Rush of Illinois. Various news reports have indicated that funding for the research lapsed Jan. 8 and have not been renewed under the Trump administration. The call for confirmation comes after recent mass shootings that resulted in 59 deaths and 500 injuries in Las Vegas and 26 people in Sutherland Springs, Texas. On Tuesday, a gunman in Northern California killed four people and wounded a number of others at random. In response, as in past shootings, some Democrats have been working to push for research on gun violence, calling it a public health issue. Gun rights advocates, including many Republicans, have said that framing is a thinly veiled attempt to eventually seize firearms or limit gun access. Pallone and Rush asked NIH Director Francis Collins, a holdover from the Obama administration, to answer whether the program has been discontinued, and if so, why.

RUNDOWN

Axios Healthcare profits concentrated at drug companies

Bloomberg Obamacare noses into the tax debate, bringing baggage

Washington Post Here’s how a rollback of key Obamacare element could stymie the law’s full repeal

Kaiser Health News Trump administration plan to add Medicaid work requirement stirs fears

New York Times Americans are putting down the soda pop

STAT News Long-awaited study finds monthly Vivitrol as effective as daily pill for opioid addiction

Wall Street Journal Senate Republican plan to repeal individual mandate risks higher premiums

Roll Call HHS pick at odds with Trump’s rhetoric on drug prices

Calendar

WEDNESDAY | Nov. 15

Nov. 13-15. Crystal Gateway Marriott. National Alliance of Healthcare Purchaser Coalition. Details.

Noon. 2075 Rayburn. Cato Institute event on telemedicine. Details.

2 p.m. 1225 I St. NW.. Bipartisan Policy Center announces “My Healthy Weight” initiative. Details.

3:30 p.m. House Capitol Room 8. Capitol Hill briefing on maternal mortality held by ACOG, the Preeclampsia Foundation, the Society for Maternal-Fetal Medicine, and the March of Dimes in cooperation with Reps. Jaime Herrera Beutler and Lucille Roybal-Allard, co-chairmen of the Congressional Caucus on Maternity Care.

THURSDAY | Nov. 16

Nov. 16-17. National Academies of Sciences, Engineering and Medicine colloquium on the Science of Science Communication. Details.

8 a.m. Boston. Opioid Insights for Action Day at the OptumLabs. Details.

8 a.m. 1777 F St. NW. The Hill event on “Preparing for a Treatment: Managing and Delivering an Alzheimer’s Breakthrough.” Details.

Noon. President Trump to visit GOP Senate lunch to discuss tax bill.

MONDAY | Nov. 20

9 a.m. 1789 Massachusetts Ave. NW. American Enterprise Institute event on “The future of delivery system reform.” Details.