What the Heller

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Defector of the Day: Dean Heller

Each day leading up to the Senate vote, we'll take a closer look at a Republican senator who seems to be on the fence on the Better Care Reconciliation Act, what they want, and what role they're likely to play in the debate. Let's start in the great Silver State of Nevada, the home of Sprinklecare, with Sen. Dean Heller.

Photo by David Calvert/Getty Images

Sen. Heller held a late-Friday press conference where he announced he could not support the Senate bill in its current form.

"In this form, I will not support it," Heller said in a joint press conference with Republican Gov. Brian Sandoval. "Make no mistake, the ACA needs fixing. But the bill in front of us doesn’t make those fixes."

Heller's main objection to the Republican repeal efforts centers on the deep cuts to Medicaid. The Senate bill, like the House bill, would end the Medicaid expansion and make deep cuts to the rest of the program, too. The House bill would cut $880 billion from the program, according to the Congressional Budget Office.

"It doesn’t protect Nevadans on Medicaid," Heller said during his press conference.

It was notable that Heller did his press conference with Gov. Sandoval, a Republican who has increasingly become an outspoken advocate for Medicaid expansion. Earlier this week he signed onto a letter with six other governors (two Republican, three Democrat) opposing the House-passed health bill because of its big Medicaid cuts.

"It calls into question coverage for the vulnerable and fails to provide the necessary resources to ensure that no one is left out, while shifting significant costs to the states," that letter argued. "Medicaid provisions included in this bill are particularly problematic.

What it would take to get Heller to yes: The senator didn't rule out entirely supporting a Senate repeal bill. Whatever brings him on board is going to require at least some more Medicaid funding.

One moment I thought was notable was when a reporter asked Heller whether he could support any bill that phases out Medicaid expansion. He didn't flat-out say no, he wouldn't support that kind of bill. Instead, he gave a more general answer about why it's important to "prop up Medicaid" and not turn back the clock on the program. This answer suggests that it's possible we could see Heller get behind a bill that does phase out the expansion, but perhaps on a different timeline.

The Senate tax credits squeeze middle-age, middle-income Americans

The tax credits in the Senate bill would ask older Obamacare enrollees to pay higher premiums — and under the Senate bill, old starts at 40.

Vox's graphics editor Javier Zarracina pulled together this incredibly helpful chart on the amount of income Obamacare enrollees are expected to pay for premiums. You can see that the caps go up significantly for those who are somewhat older. The red thresholds are those where Obamacare enrollees are asked to spend more money.

Javier Zarracina/Vox

The Senate bill would especially squeeze middle-aged Americans who are low- to middle-income. They are the people at the right end of this chart who would be asked to spend a larger percentage of their income on premiums. For someone with earnings around 350 percent of the poverty line, this would be a big jump: from spending 9.7 percent of income on premiums under ACA to 16.2 percent under the Senate bill.

It's also important to keep in mind that people would be purchasing worse health insurance with these higher contributions. As I discussed in my explainer yesterday, the subsidies under the Senate bills are benchmarked to plans that provide less comprehensive coverage than those under current law.

Chart of the Day

Kaiser Family Foundation

A majority of Americans now say they like Obamacare. That's a first. The health care law's recent uptick in popularity continues in the latest Kaiser Family Foundation poll.

Kliff’s Notes

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

News of the day

• "Top health insurer group won't take position on Senate bill" “The leading industry group for health insurers says it is not taking a formal position on the Senate's ObamaCare repeal bill, though it praised the measure's changes to the private market while criticizing its Medicaid cuts. "We are not taking a support or oppose position," Kristine Grow, a spokeswoman for America's Health Insurance Plans (AHIP), told The Hill.” —Peter Sullivan, The Hill
• "Governors Wary of Medicaid Cost Shift in Senate Health Bill "Governors in several states that opted to expand Medicaid under former President Barack Obama's health care law are wary of the Senate Republican plan to end the added federal funding for it within seven years. The proposal released Thursday calls for a slower phase-out of the Medicaid expansion than a bill adopted earlier by the House. Yet it still would force those states to figure out what to do about the millions of lower-income Americans who used it to gain health coverage.” —Associated Press
• "‘We have to get back on track’: Democrats lose patience with Trump on drug pricing" “President Trump spent the last several weeks blasting Democrats for refusing to work with Republicans on health care. Now, two of the Democrats who have shown the most willingness to work with him on one specific health issue ― drug pricing ― are blasting him back.” —Erin Mershon, STAT
• "‘Coverage Gap’ For Poor May End, But Many Will Still Have Trouble Affording Plans" “Gary Claxton, director of the Health Care Marketplace Project at the Kaiser Family Foundation, said expanding subsidies doesn’t mean the poor will find affordable coverage. “It will give people plans that are very difficult to use at their income levels,” he said, noting the coverage will likely have deductibles of over $6,000 a year.” —Phil Galewitz, Kaiser Health News

​Analysis and longer reads

• "Senate Republicans’ claim of saving individual health insurance markets could prove hollow"
• “Legislation that the Senate’s GOP leaders finally disclosed on Thursday would keep billions of dollars flowing — but only for two years — to health plans that have been begging for continued help with the expense of millions of lower-income customers in ACA insurance marketplaces. After 2019, the payments would stop.” —Amy Goldstein, Washington Post
• "For this GOP senator, rejecting the health-care bill should be a no-brainer" “[Sen. Dean] Heller will be under pressure to get in line with party leadership and the White House. However, there is no member with a bigger need to claim to one of the two “no tickets,” the number of votes Senate Majority Leader Mitch McConnell can lose and still win passage of the bill. Heller had better put in his dibs early before others announce they can never vote for a bill this bad.” —Jennifer Rubin, Washington Post
• "Those Moderates Are Screwing Up Health-Care Reform" “It is not a repeal or replacement of Obamacare. If it passes, taxes, spending and premiums would be lower. But Obamacare’s basic regulatory structure would remain in place, more so than under the House version of the plan. The Senate bill kept that structure to keep moderate Republicans on board.” —Ramesh Ponnuru, Bloomberg
• "Senate healthcare bill is an Obamacare rescue package" “Senate Republicans owe their majority to their seven-year pledge to repeal and replace Obamacare. But the draft legislation unveiled by Senate Majority Leader Mitch McConnell, R-Ky., reads less like an Obamacare repeal bill and more like an Obamacare rescue package.” —Philip Klein, Washington Examiner

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