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The perilous path for Alexander-Murray to become a law

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Ever since it was announced, the future of the bipartisan deal from Sens. Lamar Alexander (R-TN) and Patty Murray (D-WA) to stabilize Obamacare has gotten muddier.

As a matter of policy, the deal (explained in more detail here) provides some clear wins for both sides. Obamacare's cost-sharing reductions are paid, after President Donald Trump pulled them, a win for Democrats who want the law to work. On the Republican side, states will get more flexibility and consumers get some more insurance options.

But this is Obamacare we're talking about. After years of partisan warfare, a sensible compromise isn't going to just sell itself.

The picture got a little clearer, at least in the Senate, on Thursday. Alexander and Murray announced 24 co-sponsors for their bill, 12 from each party.

The 48 Senate Democrats were always likely to support the deal. It's had no bigger cheerleader than Senate Minority Leader Chuck Schumer.

The majority is the real question. Right now, 12 of the 52 Republican senators are willing to put their name on Alexander-Murray (Alexander plus these 11):

  • Sen. Mike Rounds (R-SD)
  • Sen. Lindsey Graham (R-SC)
  • Sen. John McCain (R-AZ)
  • Sen. Bill Cassidy (R-LA)
  • Sen. Susan Collins (R-ME)
  • Sen. Joni Ernst (R-IA)
  • Sen. Lisa Murkowski (R-AK)
  • Sen. Richard Burr (R-NC)
  • Sen. Bob Corker (R-TN)
  • Sen. Johnny Isakson (R-GA)
  • Sen. Chuck Grassley (R-IA)

That's a start, made up mostly of the more moderate end of the GOP conference.

But it means Republican supporters still have work to do. While the bill probably has the 60 votes it needs with Democrats united behind it, it's hard to imagine GOP leaders putting a bill on the Senate floor that only 12 of their own members support.

Alexander made his pitch clear in a floor speech today: People will be hurt without action, Republicans already included cost-sharing payments in their repeal-and-replace bills, and Alexander-Murray represents an actual policy win for Republicans after repeal's failure.

"Some say that’s not enough," he said. "Well, that’s more than we’ve gotten in eight years."

Though Alexander will undoubtedly do his best, many — maybe most — Republicans won't willingly vote for a standalone bill that fixes Obamacare after they spent nine painful months trying to repeal it.

Noting that there seemed to be 40 votes in the Senate for any repeal bill, a GOP health care lobbyist told me: "The same herd mentality there puts you at a deep hole in the Senate" on Alexander-Murray.

Instead, Democrats are likely going to have to force the issue.

We should reset our expectations: The deal almost certainly won't pass on its own. So let's look ahead to December, when the federal government needs to be funded.

"That’s your place that Republicans can more comfortably let it move," the lobbyist said.

Government spending bills need 60 votes, so the minority has a lot of leverage. But Alexander-Murray won't be the only thing they want. Democrats are also eager to resolve the DACA issue, after Trump said he would end that protection for certain undocumented immigrants.

Schumer and House Minority Leader Nancy Pelosi are going to try to get everything they can in a shutdown deal — and they have a proven record of winning Trump to their side.

But if this should become a tit-for-tat negotiation, the question will be where Alexander-Murray ranks among the Democratic priorities. It will be competing with DACA and, potentially, the Children's Health Insurance Program, which is heading into its third week without being reauthorized. Trump will want something (the "wall"?) in return.

This is going to be messy. And then you have the House, where Speaker Paul Ryan has already tried to pour cold water on the deal. He could end up being squeezed the most if Alexander-Murray gets folded as expected into the end-of-the-year talks.

"It sucks being Paul Ryan," the lobbyist said "What I can’t figure out is how he gets out of December without 150 Republicans against something."

So we know how Alexander-Murray could pass:

  • Democrats make it a must in the shutdown negotiations
  • Alexander gathers enough Republican supporters to make it palatable in the Senate
  • Ryan accepts it as a necessity in the House to keep the government open
  • Trump stays on board, after his waffling over the past few days

But that is a road filled with landmines. It's going to be an interesting two months for the deal.

Chart of the Day

Javier Zarracina/Vox

How big candy turned chocolate into a health food. You've probably heard those reports about how good for your heart dark chocolate might be. What great news, you thought. Something delicious and healthy.

Vox’s Julia Belluz has some bad news for you: Many of the studies purporting to find health benefits from eating chocolate were brought to you by, you guessed it, the candy industry. Almost every study funded by Mars, as the chart above shows, had conclusions that were favorable to cocoa or chocolate. What a coincidence.

Kliff’s Notes

Your daily top health care reads, with research help from Caitlin Davis

News of the day

  • “Bipartisan Group Of Governors Urge Congress To Stabilize Health Market”: ““We urge Congress to quickly pass legislation to stabilize our private health insurance markets and make quality health insurance more available and affordable,” the governors wrote in the letter.” —Caitlin MacNeal, Talking Points Memo
  • “Trump: 'I'm open' to ObamaCare deal”: “President Trump on Thursday indicated an openness to a bipartisan short-term ObamaCare stabilization deal introduced in the Senate. 'We will probably like a very short-term solution until we hit the block grants,' Trump said. 'If they can do something like that, I'm open to it.'” —Nathaniel Weixel, the Hill
  • “Trump administration appeals abortion ruling”: “The Trump administration is appealing a judge's order requiring that the government allow an undocumented pregnant minor in a federally funded Texas shelter receive an abortion.” —Renuka Rayasam, Politico

Analysis and longer reads

  • “These health programs work. But in the rancor of Congress, they’ve been left in the lurch”: “These so-called “extenders” — named because the policies they describe usually need to be reauthorized, reinstated, or extended at regular intervals — aren’t especially controversial. But in the midst of partisan tension over all things health-related, the programs are facing a more uncertain future than ever before.” —Erin Mershon, STAT
  • “How Illinois hustled to protect Obamacare from Trump”: “Even before President Donald Trump announced plans last week to nix Obamacare subsidies, the Illinois Department of Insurance raced over the summer to get insurers on board with a strategy to minimize the financial pain of such a move.” —Kristen Schorsch, Modern Healthcare
  • “The Next Chapter In Transparency: Maryland’s Wear The Cost”: “Maryland is launching a new initiative to make information on the price and quality of healthcare more accessible to consumers through the website Wear the Cost. With the platform, the state has taken a decidedly different approach to improving transparency—one that engages consumers in a direct and ongoing conversation about health care costs, particularly the wide disparity among providers in terms of price and quality.” —Robert Moffit, Marilyn Moon, François de Brantes, and Suzanne Delbanco, Health Affairs

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