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In 24 hours, the Senate will vote on a mystery health care bill

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Republican senators are set to vote on a bill to repeal the Affordable Care Act Tuesday. They just don't know what's in it.

It's hard to capture what an absurd and somewhat unbelievable situation this is. Health care is a massive part of the economy. The ACA provides coverage to tens of millions of Americans. The Senate plans to vote on a bill Tuesday affecting all of that. And at this moment — 24 hours or so before they vote — they have no idea what the bill contains.

As we discussed in last week's VoxCare, there are at least four different draft health care bills floating around right now. There are two that seem most ripe for a vote. These are:

  • The Obamacare Repeal Reconciliation Act (ORRA): This bill would repeal the Affordable Care Act without a replacement. It would have the repeal start in 2020, presumably allowing the Senate two years to come up with a replacement they would enact. But if they didn't, the consequences would be dire. The Congressional Budget Office estimates that this bill would cause 32 million Americans to lose coverage.
  • The Better Care Reconciliation Act (BCRA): This is the bill that repeals and replaces Obamacare, although the replacement will cover 22 million fewer people by 2026. This bill would repeal the Medicaid expansion and vastly scale back the subsidies middle-income Americans receive in the private market. The BCRA has been through multiple iterations at this point, and we still don't know what is in the latest version. Late last Friday, we found out that key provisions of the bill — the waiting period to penalize those who decide to go uninsured, for example — would be stripped from the bill for procedural reasons.

The lack of clarity is part of a larger lack of direction for Senate Republicans' six-month health care effort.

Throughout this process, Republicans have struggled to articulate what exactly they want to achieve — aside from delivering on a seven-year campaign promise to repeal and replace Obamacare.

Is the point to wipe Obamacare off the books and go back to the old health insurance system? To come up with a new health system that costs less? Or covers more people? The goal has become finding something that can get 50 votes, with less attention paid to what that policy actually is. When the goalposts aren't clear, you end up in a situation like the one we have now, where two bills that are quite different both seem like plausible targets for a vote.

This version of legislating is unlikely to yield great outcomes. As my colleague Dylan Scott has pointed out, there are key pieces missing from the Better Care Reconciliation Act after the Senate parliamentarian ruled out policies that couldn't pass through reconciliation, a process that requires only 51 votes. This includes a six-month waiting period for those who have a break in their insurance coverage. The whole point of this policy was to encourage healthy people to purchase insurance, to hold down premiums for everyone else.

From what we can tell, this policy is now stripped from the Republican bill without an apparent replacement. Will senators vote for a bill without the waiting period, and hope for the best? Do they have another policy they think can take its place?

Legislative details matter a lot. We've seen this prove especially true in the case of the Affordable Care Act, where seemingly tiny legislative details have blown up into Supreme Court cases that threaten to take down the entire law. This happened not once but twice, in court battles over the individual mandate as well as the health law's premium tax credits.

When it comes to policy, meanwhile, the details are everything. They are the line between whether a 6-year-old boy with $3 million in medical bills gets to keep living in a world without lifetime limits — or whether his benefits could suddenly run out. The details determine who gets help purchasing health insurance, and what kind of help they receive. And right now, 24 hours from a possible vote, we have no idea what any of the details of the legislation actually are.

Meanwhile, in the individual market...

State-level regulators are still struggling with the uncertainty over what will happen next in the Affordable Care Act's individual market. They are especially nervous about the future of the cost-sharing reduction subsidies, a multibillion-dollar fund that helps pay deductibles and copayments for low-income Obamacare enrollees.

State insurance regulators are worried that if they don't get certainty soon — either from the White House or with an appropriation from Congress — health plans may bail on the individual market. They'd expect this to happen sometime in September, which is when insurance plans must decide whether to sign contracts to sell on

"When we get to the end of September, insurers will need to decide, do I feel comfortable signing a contract that is going to bind me to the market in 2018," says Julie Mix McPeak, Tennessee insurance commissioner and president of the National Association of Insurance Commissioners. "I'm concerned that the lack of certainty might cause some carriers to decide they need to leave."

The National Association of Insurance Commissioners sent Congress a letter late last week urging an appropriation for the CSR funding. But getting traction on moving an Obamacare fix, at a moment when the focus is on Obamacare repeal, has proved difficult.

"Everyone understands how important this is to the continuation of the market," McPeak says. "The question is whether they can decide on the best path forward on health care."

Chart of the Day

Aaron Sojourner and Ezra Golberstein/Health Affairs

Medicaid expansion states have fewer unpaid medical bills among low-income residents. New research on the blog of the journal Health Affairs finds that unpaid medical bills declined more significantly in states that expanded Medicaid. Read the full thing here.

Kliff’s Notes

With research help from Caitlin Davis

  • "The GOP Repeal Plan Sucks. But Is It Better Than Nothing?": “It’s possible, of course, that AHCA negotiations will begin with moderate proposals and transform into something free-market oriented. With widespread opposition from conservative groups — Heritage Action, FreedomWorks, etc. — the American Health Care Act looks like a non-starter. Then again, who are we kidding? The truth is that conservatives probably find themselves in the same situation frustrated liberals did in 2009.” —David Harsanyi, the Federalist
  • "Health-Care Companies See Big Risks in Plan to Replace Obamacare": “‘Right now, we have a market that is incredibly unstable and is really on fire,’ said Tom Policelli, chief executive of Minuteman Health, which offers marketplace plans in Massachusetts and New Hampshire. ‘This bill does not put out the fire.’” —Anna Wilde Mathews and Melanie Evans, Wall Street Journal
  • "The debate over the Affordable Care Act is really a debate over wealth redistribution": "Overall, it would be ‘a big transfer. This is a massive tax cut for unpopular industries and wealthy individuals,’ said Andy Slavitt, who was acting administrator of the Centers for Medicare and Medicaid Services during the final years of the Obama administration. ‘It is about cutting care for lower-income people, seniors, people with disabilities and kids to pay for the tax cut.’” —Karen Tumulty, Washington Post

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