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The GOP’s health care talks are stuck in a vicious cycle

I’m not sure how to tell you this, but Trumpcare is back.

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Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

This is the web version of VoxCare, a daily newsletter from Vox on the latest twists and turns in America’s health care debate. Like what you’re reading? Sign up to get VoxCare in your inbox here.

Leaders of the moderate and archconservative wings of the House Republican conference think they have a deal that could revive the American Health Care Act (like I said, I'm calling it Vampire Trumpcare, and you should too).

The deal would technically keep Obamacare's core insurance reforms, but also allow states to waive them if they set up a high-risk pool. Sarah explained the policy consequences — if a state took that option, health plans could charge sick people more for insurance and offer skimpier plans.

There are two important points to understand here.

Republicans still might not have the votes. I asked a collection of conservative and moderate aides as well as GOP lobbyists, and nobody is sure this tweak will get the bill to 216 votes. That tracks with what some top Hill reporters relayed today, as the White House pushed a plan for the House to vote Wednesday that quickly looked unrealistic.

The White House has a big incentive to make it look like something is happening. The AHCA's failure was a major embarrassment, and they are approaching the 100-day milestone with no legislative accomplishments. Plus, they aren't ready to move on a tax reform bill. So the appearance of activity on health care is better than nothing.

Lawmakers in the centrist and conservative cohorts also want to shift the blame, either to the other group or, if they somehow pass something out of the House, to the Senate.

"I think they are just trying to save face in the House and couldn't care less what happens to it in the Senate," one GOP lobbyist told me.

The bill seems stuck in a vicious cycle as lawmakers try to appease both extremes of the GOP.

Think of it as the Obamacare ouroboros. (That's the snake that eats its own tail, symbolizing eternity.)

Every new policy idea to satisfy the conservatives creates a new problem for the moderates, which leads to a new policy to satisfy them. Round and round again.

The latest tweak illustrates it perfectly:

  • If the bill passed, the letter of the law would still prevent insurers from denying coverage based on a person's medical history, one of Obamacare's core reforms. So moderates can claim they are protecting people with preexisting conditions.
  • But to appease the archconservatives, they want to allow states to opt out of two other insurance reforms, which prohibited plans from raising premiums because of preexisting conditions and which required plans to cover certain benefits. But without those policies, prohibiting outright discrimination doesn't matter. Plans will hike premiums or tweak their benefits to weed out costly patients. So people with conditions are at risk again.
  • To make up for that, they want to require states that waive those protections to set up a high-risk pool to offer coverage to sick people. So moderates can still claim they are protecting these people.
  • But because of the conservatives, they won’t provide the funding experts say is necessary to really make those high-risk pools work. So people are at risk again.

It's dizzying, I know. But this merry-go-round explains why House Republicans are struggling to find an equilibrium and pass a health care bill. It's not at all clear this latest plan solves that fundamental problem.

Chart of the Day

Javier Zarracina/Vox

Obamacare is more popular than Trump. In the GOP's mad rush to repeal the law, a funny thing happened: Americans started to like it more. They now like the ACA more than any major Republican, including the president. Read more from Ezra Klein here.

Kliff's Notes

With research help from Caitlin Davis

  • "White House plans Obamacare showdown next week": “The White House is pushing for another showdown vote on repealing Obamacare next week, to coincide with President Donald Trump hitting his 100-day milestone in office. ... But Republican congressional leaders are skeptical the vote can happen so quickly. ‘The question is whether it can get 216 votes in the House and the answer isn't clear at this time,’ said a senior GOP aide.” —Adam Cacryn and Josh Dawsey, Politico
  • "Insurers Offer Early Sign of ACA Exchange Plans for 2018": “Anthem Inc. made preliminary filings indicating it will offer plans on the Affordable Care Act marketplaces in Virginia and Kentucky next year, providing an early signal on the insurer’s exchange business. Cigna Corp. and Aetna Inc., which like Anthem have said they are reconsidering their exchange offerings, are among the insurers that made similar filings in Virginia.” —Anna Wilde Mathews and Louise Radnofsky, Wall Street Journal
  • "Many Veterans Gained Health Care Through The Affordable Care Act": “Almost half of all veterans are enrolled in the VA health system; others get health care through employers or Medicare. But some don't quality for those options, and others don't know that they have them. Two years after the ACA's implementation, 429,000 veterans under the age of 65 gained coverage, which is a 40 percent drop in vets without insurance from 2013 to 2015.” —Jessica Boddy, NPR

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