Health care state of play: New bill and waiting for CBO

Senate GOP leaders and the Trump administration are not going into this week in any better of a position on health care than they were on Friday after Sen. John McCain came out against their party’s current proposal — and perhaps they’re facing a worse field of play. 

Sen. Susan Collins said on CNN’s “State of the Union” it is “very difficult for me to envision a scenario where I would end up voting for this bill.” 

Sen. Rand Paul, on NBC’s “Meet the Press,” said he would consider coming around if the central element of the entire proposal — the block granting of Obamacare’s funds — is scrapped.  

McCain is a firm no. Sen. Lisa Murkowski is still studying the proposal. Sen. Ted Cruz said Sunday he isn’t there yet in terms of support. 

When you can only lose a total of two votes, that would appear to be a pretty significant numbers problem. 

Still, GOP aides made clear they were “all in” over the course of the weekend, and sure enough, a revised proposal designed in large part to win over the skeptical or opposed appeared late Sunday night. 

What to watch Monday

1. Revised Graham-Cassidy proposal will officially be unveiled.

2. Preliminary CBO score expected as soon as Monday morning.

3. Senate Finance Committee hearing on Graham Cassidy at 2 p.m. ET.

4. Senate GOP leadership will hold their weekly meeting behind closed doors at 5 p.m.

5. Any movement from Collins or Murkowski.

6. Any answers at all from the dozen or so senators who have been, shall we say, quiet about where they stand on this bill.

7. CNN Debate, Sanders/Klobuchar vs. Graham/Cassidy.

Graham-Cassidy, revised

Late Sunday night the revised version of the proposal that Graham and Cassidy have been working on hit our email inboxes. It doesn’t take very long to see that there are some very specific targets in this bill (see: Alaska. Alaska. Alaska. Alaska.) 

Here’s our first look at the new additions, via MJ Lee, Lauren Fox, Tami Luhby and me: 

The bottom line: many of these revisions are very clearly narrowly tailored for Murkowski (significant boost in federal matching Medicaid funds, grandfathering of Native Americans and Alaska natives enrolled in Medicaid expansion into Medicaid, etc.) The overall formula tweaks/funding boosts are an effort to appeal to Murkowski and Collins. 

And tweaks to the regulations aspect of the proposal — which would give states even more leeway to loosen Obamacare regulations — appear tailored to address the concerns of people like Cruz, Sen. Mike Lee and to some degree Rand Paul. 

This is their best shot effort at threading the needle. We’ll see Monday afternoon if it takes at all. 

About those numbers

An internal Republican analysis circulated with the bill to GOP offices shows spending boosts states like Alaska and Kentucky.

That’s a big deal, as both were expected to take very hard hits in the bill. But notably, those increases in the projection come because they incorporate savings from ending the state match of Medicaid expansion. So in total, it’s still a reduction in health care spending in these states when compared to current law. (For example, Alaska would receive a $100 billion cut via its block grant in the bill, but the GOP analysis it would receive a boost of 3%.)

This is a feature, not a bug — a proposal like this isn’t designed to be some massive increase in spending. But reducing spending on health care is a political problem, hence the revisions. The analysis also doesn’t address the overhaul of the Medicaid program, from an open-ended entitlement program to a per person cap. This is all important as that analysis is being given to senators as evidence they should come around. 

On regulations it certainly gets closer to Cruz. But despite funding boosts, those same regulations provisions likely move it further away from Collins. And when it comes to Paul, well …

Will the Senate vote on anything?

First things first — nothing has been scheduled yet and a final decision either way likely won’t be made after GOP senators have their closed-door conference lunch on Tuesday. But for sake of explaining things, you basically have two camps right now — the Sen. Lindsey Graham camp, which is determined to have a vote no matter what, and the, shall we say, other camp. Which wants no part of either:

a) Another embarrassing floor failure for all to see. 

b) Somehow finding a way to get the votes on the motion to proceed to move onto the bill, then enter a vote-a-rama with no clear end-game and limited (or no) pathways to 50 votes on a final product. Which would lead back to A.

Who wins out between the two camps? We’ll see. Majority Leader Mitch McConnell operates through consensus — it wasn’t his plan to even restart this process, but it’s what his conference wanted so he went all in. But he’s keenly aware of the big lifts on other key agenda items that are staring the conference in the face (reminder: this week is tax reform launch week!) and doesn’t want to do anything to stunt progress on those. He’s also keenly aware of putting his members in the unenviable position of voting for a product with limited outside support (seriously, even conservative groups are at best holding their nose and grudgingly supporting this) if it doesn’t have a clear path to passage. 

All that said, his team has been all in the last 72 hours trying to find a path forward. Time will tell if one appears at some point before the end of the week. 

Always a good reminder

Marc Short, the White House legislative affairs chief, said Sunday a vote would occur on Wednesday. The majority leader’s office has been clear that as of this moment, no vote has been scheduled. That’s important because, well, the majority leader decides what goes on the floor when. Best to stick to Hill for all things scheduling related this week.

What to expect from the CBO score

Not much, which clearly irked McCain.

The CBO said last week the best it could do in such a compressed time table was a “preliminary” report — one that shows the deficit reduction numbers that are key to whether or not the bill complies with budget rules. It is expected to pass that test — at least for the initial draft of Graham-Cassidy.

But that, of course, is no longer the working draft and it’s unclear how quickly they’ll be able to turn around a revised score for the new version of the bill. And perhaps a bigger issue is coverage numbers, and estimates for what would happen to premiums, are not expected to be included. Is this in and of itself a death knell for the bill? Not necessarily — Republicans have made no secret of their distaste for how the CBO models their health care proposals. But it does matter to McCain. And it does matter to Collins. And moving forward without a full score is akin to writing a fresh round of political attack ads for Democrats in the 2018 cycle. 

How this bill gets through the Senate

There’s a limited amount of optimism about the path forward for this bill, but here’s the way this could actually happen, per multiple sources involved: 

Find some way to get Murkowski on board — all the stops are being pulled out to do just that. If that were occur, all eyes would shift to Paul. At the moment, it’s primarily the White House that has taken on the responsibility of trying to pull Paul back from his firmly entrenched “no” position. If Murkowski gets to yes, then that will turn into an all-out blitz from everyone — from Capitol Hill, to outside conservative groups, to the President. 

The goal would be to get 50 for the procedural vote, then start making deals — whether it’s a promise of amendment votes, or clear policy changes, the idea would be to find some way to thread an incredibly complicated needle over the course of the vote-a-rama that would immediately follow the procedural vote. 

Is it likely? Again, significantly more skepticism than optimism. But in the minds of those working on this, that’s the way it could happen. And yes, it all hinges on Murkowski right now.

The wildcard returns

Don’t forget, this proposal will still need to go through the so-called “Byrd bath,” where the Senate parliamentarian takes a look at various provisions and recommends whether they pass muster under budget rules.

That could create new problems nobody outside of senior budget staffers have gotten their heads around yet. This isn’t as high profile as last time around because leaders don’t have the numbers yet. But if they manage to get them, and then, say, the Obamacare regulation opt-out language, or the effective one year defunding of Planned Parenthood get stripped, a whole new world of potential problems opens up. 

The players
Lisa Murkowski

Murkowski spent the weekend back in Alaska studying the proposal and all sorts of numbers, from administration, from Graham and Cassidy and from her state agencies. Senior GOP aides aren’t optimistic she’ll come around — they point to where her governor has firmly been (opposed), they point to Alaska’s extremely complicated and unusual health care needs, they point to the reception she received back home when she helped vote down the effort in July.

But the effort to get her to yes is concerted, real and of the all-hands variety. Changes clearly were made to benefit her state in the most specific of ways. It’s anyone’s guess it will do the trick, but it can’t be argued that supporters of the bill haven’t gone all out to get her to yes.

Rand Paul

No GOP senator — heck, few Democratic senators — have so viscerally attacked Graham-Cassidy like Paul. His opposition has remained firm throughout, despite the wide belief off Capitol Hill that if it came down to it, he’d eventually come around. 

Paul appeared to open the door a sliver on Sunday when he announced he’d consider supporting the bill … if it stripped the central mechanism of the bill: the block grants that utilize Obamacare’s subsidy and Medicaid expansion money to parcel out $1.2 trillion in funds directly to states. 

He has also been clear that Obamacare’s regulatory infrastructure needs to be cut back to a significant degree further for him to have any interest. 

The former is essentially non-starters in the bill — it would render it a completely different proposal, which isn’t by accident. Paul wants a completely different proposal. The latter is closer to where Paul wants to be in the revised version. But far from what he would prefer.

In July, Paul was willing to support the motion to proceed in exchange for an amendment vote. He supported the “skinny repeal” plan because it was “better than no repeal.” This is the basis for people — including the President apparently — thinking he can eventually come around. 

Maybe the door continues to slowly creak open, but Senate GOP aides aren’t optimistic. Why? Well, presenting this tweet from Sunday: “I didn’t run to put a cap ON Obamacare, I ran to put a cap IN Obamacare #killObamaCare #nofakerepeal”

Ted Cruz

Cruz said on Sunday that he wasn’t quite there yet on the proposal, but wanted  to get to yes. This was misinterpreted by many — Cruz wasn’t saying he’s a “no.” In fact, last week at one point he said things were “moving in the right direction.”

Cruz’s point is he has specific asks — while he hasn’t outlined them in detail, his push has always been pushing to cut back Obamacare’s regulations. This issue is actually addressed in the revised bill — states have a significant amount of new flexibility to rid themselves of the regulations. The key here is he’s in the game and looking for specific changes, not just outright opposing anything. It’s unclear whether those changes are attainable, but he’s far from a firm “no” and shouldn’t be treated as such. 

Others

Go ahead and take a look at the “unclear” column in CNN’s whip count, which Ashley Killough has painstakingly maintained up to the minute for the past week: 

That’s a lot of folks, right? Now, to be sure, the vast majority of them are expected to be solid “yes” votes in the end. But there’s a handful in there, sources say, that have quietly expressed serious concerns with the proposal. Will they all come around? Totally possible, if not probable.

But it’s safe to say there’s a group of GOP senators who aren’t thrilled about the policy but don’t want to make a show of it. Right now things don’t look good for the bill, but should things start gaining momentum, keep your eyes open for new problems to emerge from one (or more) of the individuals in that group. 

Final note

Graham said something really interesting Sunday that’s worth keeping a close eye on. In his interview on ABC’s “This Week,” he suggested he and Sen. Ron Johnson, a Wisconsin Republican, were “not going to vote for a budget resolution that doesn’t allow the health care debate to continue.” 

Given the 2018 budget is the mechanism for unlocking tax reform (and senators struck an agreement on it last week), that would seem to be a very significant statement. If the latest repeal effort does go down, we’ll see if it holds, but keep an eye on this.