Another government shutdown over Obamacare? Only if Trump wants it.

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Health care wonks are mysteriously, reliably attracted to things in groups of three.

You have Obamacare's "three-legged" stool that economists constantly discuss. House Speaker Paul Ryan spent the past few months talking about his "three-pronged" approach to Obamacare repeal and replace.

So it only makes sense that this week's fight over whether to fund Obamacare's cost-sharing reduction subsidies — and possibly cause a government shutdown in the process — has three distinct factions at odds.

Think of this week's debate over the Obamacare subsidies, which help insurers offer discounts on deductibles and copays for low-income Americans, as a negotiation between three teams: congressional Democrats, congressional Republicans, and the White House. We already know a little bit about what each team wants to get out of any sort of budget deal.

Congressional Democrats want to get Obamacare's cost-sharing subsidies funded. House Minority Leader Nancy Pelosi (D-CA) and Senate Minority Leader Chuck Schumer (D-NY) have been quite clear on this: It is a key priority to get the Obamacare subsidies appropriated in this upcoming budget. Ideally, Democrats want a permanent appropriation for these subsidies, which come out to about $8 billion annually. Realistically, they'd likely settle for an appropriation that lasts through 2018, which would do a good deal to reassure health insurers that are deciding whether to sell on the Obamacare marketplaces next year.

Congressional Republicans seem to want to fund the Obamacare cost-sharing subsidies too. Every indication we've had from top House Republicans is that they understand ending the cost-sharing subsidies would blow up the Obamacare marketplaces — and they are not in the mood for that sort of chaos. Here's an important section from a recent article in the New York Times on the topic:

Two influential Republicans — Representatives Tom Cole of Oklahoma, the chairman of the Appropriations subcommittee responsible for health spending, and Greg Walden of Oregon, the chairman of the Energy and Commerce Committee — said Congress should appropriate money for the cost-sharing subsidies.

“I don’t think anybody wants to disrupt the markets more than they already are,” Mr. Cole said in an interview. “It’s a very unstable market.”

Asked if he thought Congress should provide the money, Mr. Cole said, “My personal opinion is yes.”

Likewise, Mr. Walden said last month, “I will do everything I can to make sure that the cost-sharing reduction payments get made.” That, he said, is “an obligation we have not only to the insurers,” but also to consumers, and “we cannot leave them high and dry.”

We don't know where the Freedom Caucus, the most conservative Republicans who want Obamacare repealed altogether, stands on the issue. But given that Democrats support the subsidies, the far-right wing just doesn't have as much leverage here.

The White House wants ... well, we don't really know. Traditionally you'd expect a Republican White House to be playing on the same team as a Republican Congress. And they might well be! But the Trump administration certainly hasn't made it clear whether it shares legislators' views that the subsidies ought to continue.

Instead, the administration has put out confusing statements that waffle on whether they want to continue this part of Obamacare — or are jonesing for a big fight. They pushed back on a New York Times article reporting that they supported continuing these subsides.

"The administration is currently deciding its position on this matter," Health and Human Services spokesperson Alleigh Marré said at the time. "We have not been contacted by Democrats to help save Obamacare, perhaps because they consider Obamacare to be a losing cause. Democrats need to help solve this failed Obamacare plan."

There was a cryptic Trump tweet on the topic over the weekend.

And one White House official who talked to the New Yorker's Ryan Lizza certainly seemed to be girding for conflict:

“This is going to be high-stakes poker,” the White House official said. When I asked if a shutdown was likely, the official paused for several seconds. “I don’t know,” the official said. The official added, “I just want my wall and my ICE agents.”

The big unknown on the larger Obamacare repeal-and-replace battle is whether congressional Republicans can come to an agreement on which policies they support.

But this fight is different. The big question is whether congressional Republicans and the White House want the same things out of the upcoming budget bill. And that will determine not only if this Obamacare program gets funded but also if the government stays open.

Map of the Day

Guttmacher Institute

An estimated 6.2 million women received contraceptives at 10,700 publicly funded clinics across the country in 2015, according to the Guttmacher Institute. A new report from the nonprofit also maps where those clinics are.

Kliff's Notes

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

News of the day

• "Paul Ryan: No vote scheduled on Obamacare repeal next week": “House Speaker Paul Ryan told GOP lawmakers Saturday there is no vote scheduled next week on a new healthcare reform bill as talks continue on reaching a deal between conservatives and moderates on how to repeal and replace Obamacare. ‘He was clear there will be a vote only when we know we can pass the bill,’ a source who listened to Ryan during an afternoon conference call with Republicans, said. ‘The votes will drive the timing.’ Ryan, R-Wis., told Republicans the House will focus next week on passing a spending bill to keep the government open past an April 28 deadline.” —Susan Ferrechio, Washington Examiner
• "Downside to holding Obamacare hostage to pay for Trump’s wall? Obamacare is more popular": “Last week, budget director Mick Mulvaney introduced a new strategy from the administration. For every dollar that Congress approves for building the wall, Trump will accept a dollar spent on paying insurers to subsidize health care under the Affordable Care Act. Government funding is central to the Affordable Care Act’s viability, and if the administration were to oppose that funding, the health-care program would be severely undercut. In other words, the administration hopes to use Democrats’ support for the Affordable Care Act — Obamacare — as leverage for getting them to approve funding for the wall.” —Philip Bump, Washington Post
• "Pence cuts trip short to help Trump with spending bill, healthcare": “An aide on Pence's 10-day trip to Asia and Hawaii told reporters that the trip would be ending earlier than planned, according to a pool report. Pence will stay in Hawaii briefly on Monday and then head back to Washington in order to help Trump avoid a partial government shutdown that would go into effect after Friday if Congress can't pass a new spending bill. Pence is also aiming to help Trump reinvigorate his push for healthcare reform and roll out his tax reform package on Wednesday. Pence will return to Washington on Tuesday.” —Kyle Feldscher, Washington Examiner

​Analysis and longer reads

• "Why State Governors Will Determine the Future of US Health Care":
• “If Trump and congressional Republican leaders succeed in their goal of dismantling Obamacare and shifting much of the responsibility for health care to the states, then the nation’s governors will likely have an important say in how it plays out. Currently, 33 of the nation’s 50 governors are Republicans, many of whom are sharp critics of Obamacare or opposed allowing their states to participate in expanded Medicaid for low-income adults under the Affordable Care Act.” —Eric Pianin, Fiscal Times
• "A Good Deal For Eliminating Hepatitis C: Saving Money And Lives": “A recent consensus committee of the National Academies of Sciences, Engineering, and Medicine proposed a novel strategy to improve access to hepatitis C medicines. Their report recommends that the firms producing the hepatitis C treatments compete to license their patent to the federal government for use in neglected patients, such as Medicaid beneficiaries and prisoners. Such a deal would protect the innovator companies’ market share in the lucrative private markets, while allowing the government to save billions of taxpayer dollars and reach more poor patients.” —Neeraj Sood, Gillian Buckley, and Brian Strom, Health Affairs Blog

"Health Care In America: An Employment Bonanza And A Runaway-Cost Crisis": “‘The goal of increasing jobs in health care is incompatible with the goal of keeping health care affordable,’ said Katherine Baicker, a Harvard University health economist who sees advantages in trimming the industry’s growth. ‘There’s a lot of evidence we can get more bang for our buck in health care. We should be aiming for a health care system that operates more efficiently and effectively. That might mean better outcomes for patients and fewer jobs.’ But the country has grown increasingly dependent on the health sector to power the economy, and it will be a tough habit to break.” —Chad Terhune, Kaiser Health News

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