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The Senate health care debate is getting a little kooky

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.

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Things are getting weird in the Senate.

The official group of senators working on the health care bill — I think Sarah and I have settled on Brocean's 13, thank you readers — is meeting three times a week. They have talked about Medicaid. They've talked about insurance premiums. They've talked about stabilizing the market for 2018.

But the Senate is still a ways away from a cohesive health care plan. How can you tell? Because we're hearing a lot of ... unusual health policy ideas get floated.

Some of them sound plausible. Others, less so. It can be a lot to keep up with. Here is what's popped up in the last week and what you should know:

1) Let's have states opt into Obamacare's regulations, not out of them

Conservatives like Sen. Mike Lee are suggesting this twist on the MacArthur Amendment that helped the American Health Care Act pass in the House. That amendment allowed states to waive some Obamacare regulations, such as the prohibition on insurers charging sick people more than healthy people, with a few conditions.

Lee is flipping the idea around: He wants to make a waiver (or repeal, if you rather) the default — but let states keep the regulations if they want to.

Politically, that's hard to imagine. Key swing votes, like Sen. Susan Collins (R-ME), have already told me they're worried about how the bill could affect people with preexisting medical conditions.

But there is one procedural reason to take it seriously. The MacArthur Amendment could run afoul of the Senate rules Republicans are using to avoid a Democratic filibuster, which require provisions in the bill to have a direct budget impact.

I'm told that how many states are expected to take a waiver, and the resulting budget consequences, will help determine whether the amendment would fly. So making waivers the default option could actually make it easier for the policy to work under those rules.

2) Let's auto-enroll people into some kind of health insurance plan

Senate Republicans are talking pretty openly about how their plan could automatically enroll uninsured people into some health coverage, likely bare-bones catastrophic insurance, unless they decide they don't want it.

CNN reported that Sen. Lamar Alexander (R-TN) floated the idea in a closed-door meeting as a condition for waiving Obamacare's regulations, and Sen. John Thune (R-SD) told reporters he has been trying to start a conversation about it.

"I think the question everybody has is how does that mechanism work?" Thune said Wednesday. "We want to get more people into the pool and that obviously makes it better for everybody."

That would be the rationale: Auto-enrollment covers more people and expands the insurance pool, which could help lower premiums.

This seems like it would be tough for conservatives to swallow. It might sound to them like the government forcing you into an insurance plan. Many people around DC have dismissed it out of hand for that reason, as well as the practical challenges that Thune alluded to.

But the policy has persisted, and top senators sound interested. I can tell you this: Staffers, even to conservatives, are at least taking it seriously.

3) Let's keep the individual mandate, maybe forever

In a real head-turner, Sen. Orrin Hatch suggested to reporters this week that Republicans could keep the hated penalty for not purchasing health insurance — maybe forever.


Look, I can believe that the GOP would reluctantly keep the mandate during the transition to their health care system. They've been talking a lot about stabilizing the market in the short term and, like it or not, insurers say the mandate does that. Sen. Ron Johnson (R-WI) told reporters the other day that he'd be willing to swallow policies he doesn't like in order to improve the market in the next few years.

But keeping the mandate indefinitely? That's a flat-out non-starter for conservatives, as one aide confirmed to me. Might as well say Obamacare repeal is dead.

4) Let's leave some of Obamacare's taxes, at least for a while

Some top Republicans have also said recently that they might be willing to keep some of Obamacare's taxes, at least for a while longer — even if the goal would ultimately still be to repeal them.

"We believe that repealing Obamacare means repealing the taxes. That’s the starting point, and then we’ll work from there," Thune said. "We’ve got members who have different ideas about revenues and how you might use those revenues to design features in our plan that are different from the House plan.

This one might sound surprising — Republicans keeping taxes? From Obamacare? — but it makes a lot of policy sense. The Senate is expected to increase the financial help for people to buy private insurance and to phase out the health care law's Medicaid expansion more slowly.

Both of those things cost money and, under the complex Senate rules being used by Republicans, any increased costs in their bill must be offset somehow. Delaying the repeal of those Obamacare taxes — on the wealthy, on health insurance, on drug companies — is an easy way to do it.

Chart of the Day:

Urban Institute

How much high-risk pool money is enough? Republicans want to use high-risk pools to cover people with high medical costs, and a big part of the debate has been whether they're providing enough money to make the pools work. A new analysis says no. Read more from the Urban Institute.

Kliff's Notes

With research help from Caitlin Davis.

News of the day:

  • "How a drug ad made its way into ‘General Hospital’": “Devane is a soap opera character, as you might have guessed, appearing for the last 32 years on “General Hospital.” And her dramatic diagnosis is brought to you by Incyte Corp., a biotech company that happens to market a drug for her on-screen disease, the rare blood disorder polycythemia vera.” —Damian Garde, STAT
  • "Obamacare Helped Americans Detect Cancer Earlier": “The number of Americans whose cancers were diagnosed at the earliest stage, when it’s most likely to be cured, increased after Obamacare went into effect and more citizens had access to health insurance, a new study found.” —Michelle Cortez, Bloomberg
  • "Lobby groups to watch in Senate healthcare fight": "Industry groups felt largely cut out of the House’s drafting and passage of the American Health Care Act and now are clamoring for action to fix what they view as serious defects in the legislation.” —Rachel Roubein, The Hill

Analysis and longer reads:

  • "The Racial Divide in State Medicaid Expansions": "Although overall public support is positively related to state adoption, we find that public support for the Medicaid expansion is racialized in two ways. First, there are large differences in support levels by race; and second, state adoption decisions are positively related to white opinion and do not respond to nonwhite support levels." —Colleen Grogan and Sunggeun Park, Journal of Health Politics, Policy and Law
  • "Three-Year Impacts Of The Affordable Care Act: Improved Medical Care And Health Among Low-Income Adults": "Among adults with chronic conditions, we found improvements in affordability of care, regular care for those conditions, medication adherence, and self-reported health." —Health Affairs

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