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Want to see the Senate's draft health care bill? Good luck.

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Senate Republicans are reportedly wrapping up their draft health care bill — but aren't planning to release it to the public. A Senate staffer explained the decision to Axios's Caitlin Owens as follows:

"We aren't stupid," said one of the aides. One issue is that Senate Republicans plan to keep talking about it after the draft is done: "We are still in discussions about what will be in the final product so it is premature to release any draft absent further member conversations and consensus."

It's clear, at this point, that Republicans plan to move more quickly and less deliberatively than Democrats did in drafting the Affordable Care Act. They intend to do this despite repeatedly and angrily criticizing the ACA for being moved too quickly and with too little deliberation.

We already saw this on the House side, where the American Health Care Act passed out of committee four days after the bill's introduction — and passed the House two months later, without a score from the Congressional Budget Office.

The Senate process is even more rushed. There is currently no plan for committee markups or votes. Once the bill is ready, it will go straight to the Senate floor for a vote. Negotiations are largely happening at this point in private meetings and lunches.

Compare that with the Senate process in 2009, which the New York Times's Robert Pear recently documented:

In June and July 2009, with Democrats in charge, the Senate health committee spent nearly 60 hours over 13 days marking up the bill that became the Affordable Care Act. That September and October, the Senate Finance Committee worked on the legislation for eight days — its longest markup in two decades. It considered more than 130 amendments and held 79 roll-call votes.

The full Senate debated the health care bill for 25 straight days before passing it on Dec. 24, 2009.

The Senate debate over the Affordable Care Act lasted 25 days. This was after marathon markup sessions including, as Pear notes, the longest markup in the Senate Finance Committee's entire history. Spending that much time makes sense when you're writing a bill that will re-regulate the American health care industry, one-sixth of the American economy.

In 2009, the Senate spent 25 days debating the ACA before passing the bill on Christmas Eve. Senate Republicans haven't even drafted their bill, and Majority Leader Mitch McConnell has already proposed a timeline where the body votes before their Fourth of July recess — exactly 18 days from now.

The Senate strategy seems to acknowledge that any public scrutiny of their bill will only hurt the repeal effort. There is reason to think they are right. The House bill got a dismal reception. Senate Republicans near certainly saw the tsunami of opposition — from major doctor groups and conservative health care experts — that greeted the American Health Care Act.

Over the past few weeks, we've seen the Senate bill evolving to be more like the House bill, likely to end the Medicaid expansion and possibly include changes that would make people with preexisting conditions pay higher premiums.

These types of changes are not popular. They do not poll well, and that might be a reason to not want to release them widely. But at some point, Republicans will need to vote on their bill, and in order to do that, they will need to make the text public. The public backlash is unavoidable — it's not a question of if, but when.

Iowa wants to test out "AHCA lite"

Iowa's insurance market has been struggling to attract health insurance carriers. It's currently down to just one health plan, Medica, covering most of the state.

Iowa, however, released a plan today that it thinks will draw health plans back into the market — one local insurer has even said it will rejoin if the federal government approves the proposal.

The plan is titled "The State of Iowa’s Proposed Stopgap Measure for the Individual Health Insurance Market." But read the 33-page document and you get a better sense of what this actually is: AHCA lite.

Iowa essentially wants to bring some key features of the Republican health care plan to its market. These include:

  • Switching to subsidies that are determined by age and income. This is different from the Affordable Care Act, which tethers the size of insurance subsidies to how much insurance costs in a given area (ACA gives more help to people who live in areas with more expensive premiums).
  • Lower premiums for younger enrollees and higher prices for older Iowans. As Tony Leys reports for the Des Moines Register, the goal of this policy change is to attract more young adults into the marketplace. Again, this is similar to the AHCA, which would let insurers charge older adults higher prices.
  • Subsidies for high-income Iowans. Under the Affordable Care Act, a 61-year-old in Iowa who earns $70,000 gets no help from the government paying for Obamacare premiums. Under the Iowa proposal, she would get a $117 monthly credit. It's unclear where this money comes from, or whether it is the result of lowering premiums for low-income Iowans. I've left a message with the Iowa Insurance Department requesting more details, and will update when I have the answer.

Iowa is also proposing a reinsurance program that would shore up insurance plans that end up with especially sick patients. This sounds similar to a plan Alaska is also pursuing.

The AHCA-lite parts of the plan have taken Medica, the largest remaining insurer on the state marketplace, by surprise. Medica released this statement:

The Iowa Insurance Department proposal includes some important provisions to stabilize the market that we have asked for, particularly a robust state reinsurance program. However, the proposal also includes other provisions, including significant changes to the subsidy structure that will have an impact on which consumers do and don't buy coverage. We are still analyzing those changes to help our decision-making should this proposal be approved.

Quote of the Day

Tom Humberstone/Vox

Inside the Canadian clinic that prescribes heroin. My colleague German Lopez traveled to a Vancouver clinic taking a surprising approach to treating drug addiction: prescribing medical-grade heroin.

"The idea is this: If some people are going to use heroin no matter what, it’s better to give them a safe source of the stuff and a safe place to inject it, rather than letting them pick it up on the street — laced with who knows what — and possibly overdose without medical supervision," Lopez writes. "Patients can not only avoid death by overdose but otherwise go about their lives without stealing or committing other crimes to obtain heroin."

Kliff’s Notes

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

Today's top news

  • "Senate GOP considers adding opioid funding to ObamaCare repeal bill": “Senate Republicans are considering adding funding for opioid abuse treatment to their ObamaCare repeal bill, according to senators and aides. The move would be meant to ease concerns about the effect on opioid treatment from rolling back ObamaCare’s expansion of Medicaid, which currently plays a major role in providing coverage for opioid addiction treatment.” —Peter Sullivan, the Hill
  • "Fate of Planned Parenthood funding tied to Senate moderates": “Most Republicans want to eliminate the group’s $555 million in federal funding as part of their bill to repeal Obamacare. But as Majority Leader Mitch McConnell tries to solve the legislative Rubik’s Cube of finding 50 votes for repeal, he may have to drop the Planned Parenthood cut to win the support of the two Republican moderates, Sens. Susan Collins of Maine and Lisa Murkowski of Alaska.” —Jennifer Haberkorn, Politico
  • "ACA enrollment falls to 10.3 million": “The number of people who enrolled in Affordable Care Act coverage for 2017 and paid their premiums — rather than just signing up — is 10.3 million, the Centers for Medicare and Medicaid Services announced today. That's down from the 12.2 million people who had signed up for health care plans during the ACA's last open-enrollment period, meaning 1.9 million people didn't follow through by paying their premiums.” —David Nather, Axios
  • "Blame game begins as health insurers shun two Washington counties": “Two rural Washington counties have been thrust into the national health-care debate after new rate filings revealed that no insurers planned to offer coverage next year in the individual markets in Klickitat and Grays Harbor counties. Democratic elected officials pounced, blaming the insurer pullout on uncertainty caused by Republican plans to repeal the Affordable Care Act (ACA).” —Bob Young, Seattle Times

Analysis and longer reads

  • "Flexibility That A.C.A. Lent to Work Force Is Threatened by G.O.P. Plan": “If the Republican replacement plan approved by the House becomes law, changing jobs or careers could become much more difficult. Across the nation, Americans in their 50s and early 60s, still too young to qualify for Medicare, could be hit hard by soaring insurance costs, especially people now eligible for generous subsidies through the existing federal health care law.” —Reed Abelson, New York Times
  • "A Drugmaker Tries To Cash In On The Opioid Epidemic, One State Law At A Time": “While policymakers are grasping for solutions to the nation's opioid epidemic, Alkermes, which has its U.S. headquarters in Waltham, Mass., is using policy to promote its drug and, in some cases, hamper access to medications that can help. And in so doing, it's looking to turn its drug into a blockbuster.” —Jake Harper, NPR
  • "It’s time to make it legal for Americans to order prescription drugs from abroad": “Every day, countless people across America order prescription drugs from pharmacies in other countries as they hunt for something increasingly elusive — affordable medications. But there’s a problem. Under most circumstances, importing medicines is illegal. And it is time to scrap this prohibition, unless Congress finds another way to drive down drug costs.” —Ed Silverman, STAT

"The Senate’s three tools on health care: Sabotage, speed and secrecy": “Just as in the House, we’re on track to have a vote with no hearings (there were more than 100 for the ACA). Knowing the coverage loss will be significant, McConnell plans to vote within only days, or possibly even hours, of the release of the CBO score. Moving fast leaves opponents, and the public, with no time to catch up to the details.” —Andy Slavitt, Washington Post

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