Your questions about the opaque, ever-shifting Senate health care debate, answered

The Senate is voting Thursday night on a health care bill. We don't know what's in it. Senators don't know what's in it. It's possible no one knows what's in it. And yet, "What's in the bill?" isn't the only question swirling around the debate today. There are dozens of other big ones!

That's why we've called this little meeting of Vox health care reporters, to puzzle through the many questions our readers and social media followers have about what has been — let's put this charitably — a really confusing week of Senate procedure.

We'll start with this one:

Dylan Scott: Ha! If only it were so simple.

Here’s what we know for sure: The Senate is going to start voting this afternoon on health care amendments. Technically, they will be amendments to the House’s health care bill. So they are all for show.

Behind the scenes, Senate leaders are scrambling to pull together some kind of health care bill that can get 50 votes — the so-called “skinny” repeal. They still haven’t finalized it yet, but it will likely hit Obamacare’s individual mandate, employer mandate, and maybe more. The rest we aren’t sure about yet.

At the end of the voting — which, seriously, could go all night and into the morning — we expect Mitch McConnell to introduce this “skinny” repeal bill and the Senate will vote on it. That’s the vote that counts.

That’s the best rough outline I can give. Things are changing by the minute.

Jim Tankersley: So to recap:

• They're going to vote all day and night on amendments.
• Those votes are meaningless.
• Because they will be replaced by whatever they vote on last.
• And we don't know what that will be.

Right?

Dylan: You got it.

Sarah Kliff: But! To take a step back and write out some words about where we are, it is a really unprecedented situation to have a major vote coming up in mere hours where we haven’t seen the actual text of the bill. “Skinny repeal” has never existed in legislative language. So far, it has only been a set of bullet points cobbled together by correspondents up on Capitol Hill. There were reports early this morning that the bill would be drafted over lunch today.

Here’s one thing I’ve learned covering health policy for the past decade or so: Details matter. Drafting matters. The Affordable Care Act ended up in the Supreme Court over a drafting error around its tax credits. Writing a bill so quickly is a recipe for a mess.

That being said, you could also see skinny repeal as a vehicle to force a conference committee with the House — a bill not designed to actually become law (writing bills you don’t want to become law is also an odd strategy, but I’ll set that aside from the moment). Dylan, is that a theory you believe from your perch up on Capitol Hill?

Dylan: This is the most important big picture question, I think. Are Republicans really ready to accept “skinny” repeal as all they can do? Or, like you said, is it just a vehicle to get into negotiations with the House and revive a much bigger repeal-and-replace plan?

To be clear: Senate leaders themselves are saying it’s the latter. They want a bigger bill — which, most notably, would likely cut Medicaid while skinny repeal does not — to come out of negotiations with the House. That’s what they are saying themselves.

But, privately, a lot of people are skeptical that could happen. Senate Republicans still haven’t been able to agree on a bigger bill among themselves. It seems … doubtful that adding the House to the mix is going to help things.

TL;DR: I think there is a good chance we go into conference and Republicans try to craft a bigger bill. But I also think it’s possible that “skinny” repeal really is the end game if that fails.

Sarah: Right — in a small way, this reminds me of what happened with the sequester back in 2013. Nobody really wanted the sequester policy to become law, but when they couldn’t agree on anything else, it just kind of happened. The dynamics around skinny repeal are a bit different, but I think that is a cautionary tale around how, once policies actually get introduced into the mix, they can become law — even if that wasn’t the original intention.

Jim: Our audience has a lot of other sharp, important questions. It's a question-a-rama! Let's go to it now. (We’re all going to join forces for the answers.)

We got this question a lot. Full disclosure: We are not the Congressional Budget Office or the Senate parliamentarian. So we can’t say for sure.

There are two things to consider: First, the Senate’s “skinny” bill needs to satisfy the Byrd Rule, which requires any provisions considered under budget reconciliation to directly affect federal spending or revenue.

We have good reason to believe that lowering the Obamacare individual mandate and employer mandate penalties to $0 (which is what Republicans are technically proposing, rather than repealing the mandates outright) and repealing some of the law’s taxes satisfies that rule.

But second, under reconciliation, the Senate “skinny” bill also needs to reduce the federal deficit over the next 10 years by at least as much as the House health care bill did, more than $100 billion.

This is where it gets complicated. There are a bunch of competing variables when you repeal the individual mandate: You don’t bring in as much revenue from the penalties, but fewer people are projected to use federal tax subsidies to save money. Repealing the medical device tax means less money for the federal government.

That’s the equation that CBO will have to sort out to tell us if “skinny” repeal compiles with reconciliation. Smart experts outside of Congress think there are some legitimate doubts about whether the math will work.

But we don’t know for sure what will be in the bill — and therefore, we can’t be sure whether any of this is going to work under the Senate rules.

We received several variations on this question: Are Senate Republicans just passing skinny repeal so they can go into negotiations with the House and revive a bigger repeal-and-replace bill there?

The truthful answer is: We don’t know.

Senate leaders are saying that’s what they want to do. Archconservatives in the House also say they want to start so-called “conference” negotiations and then come up with a more robust health care plan. Those talks could take weeks or longer.

The stakes are huge. Skinny repeal, by itself, leaves most of Obamacare in place and Medicaid untouched entirely. The repeal-and-replace bills Republicans have been debating this year would gut much of the health care law, end its Medicaid expansion, and overhaul the entire Medicaid program.

But here’s the problem: Senate Republicans can’t agree on their own repeal-and-replace bill. It’s not clear how negotiating with the House, with whom they have even bigger disagreements, helps resolve those issues. Republicans I’ve talked to privately think skinny repeal is the only thing that can pass both the House and the Senate.

Republican leaders are saying they want to revive a bigger health care bill, so we should take that seriously. If they come up with a plan that resembles the Senate and House repeal-and-replace plans in conference, it would need to pass both the House and the Senate again.

But they may find skinny repeal is their only choice, in the end. In that case, the House would just pass whatever skinny repeal bill the Senate passes.

The provision in skinny repeal that most affects the insurance market is eliminating the individual mandate. The CBO has projected that would, all on its own, lead to 15 million fewer Americans having health insurance 10 years from now.

The question is: Why? Obamacare supporters would say it’s because repealing the mandate destabilizes the market: Healthy people skip out on coverage, while sicker people keep buying, increasing costs to insurers. Obamacare opponents would say it’s because people now have the freedom to decide whether or not to buy insurance.

So which is it? I asked Larry Levitt at the Kaiser Family Foundation. The answer is, unsurprisingly ... complicated. It does seem true that healthy people would decide not to buy coverage, according to the CBO. That would be their right, without the individual mandate requiring them to purchase insurance.

But that would in turn destabilize the market, increasing premiums and making it harder for those who do want to buy coverage to afford it. So these two things are interconnected. Healthy people’s choice not to buy coverage would make it harder for the market to function for everybody else.

“In the individual insurance market, the people who would be most likely to not sign up for coverage without an individual mandate would be those who are healthy and believe insurance is not as good a deal for them,” Levitt said. “As healthier people drop out, premiums have to rise.”

The Trump administration can do a lot to weaken Obamacare — this is something that the people who used to run the law under President Obama roundly agree on.

"There is little question in my mind that through active mismanagement, you could do a lot of damage," says Andy Slavitt, who previously served as Medicare administrator under President Obama. "There are an untold number of ways you could mismanage this thing."

The biggest thing the Trump administration is doing right now is not providing any clarity on whether it will keep funding cost-sharing reduction subsidies, money that helps offset deductibles and copayments for low-income enrollees. This has led to insurance plans either raising premiums or deciding not to sell coverage at all.

There is even more the administration can do come November 15, when open enrollment starts. They could decide not to advertise the open enrollment period, for example, or announce they won’t enforce the individual mandate. There are little things, too, that won’t be obvious — like whether the call center for people who need help signing up will be well-staffed, or if callers will face long wait times.

For more on this topic, I’d recommend an excellent post from Louise Norris at HealthInsurance.org, who recently did a deep dive on ways the Trump administration has stood in the way of ACA implementation.

As far as we know, the only state with its own individual mandate is Massachusetts (the mandate predates the Affordable Care Act from the state’s 2006 coverage expansion). Other states haven’t had a reason to create individual mandates, given the federal requirement.

That being said, if Republicans did focus on repealing the individual mandate, I’d expect some liberal states to create these types of laws. California and New York, for example, seem like prime contenders (New York has been especially out front in codifying Obamacare provisions, like the birth control mandate, into law over the course of 2017).

How many states would want to pass an individual mandate is hard to know. This could be hard in states like Washington, which we generally think of as liberal but currently has a Republican-controlled state legislature.

As far as I know, the Congressional Budget Office has not accounted for the possibility of state-level individual mandates in its analysis of the provision.

Now for the lightning round:

Yes! Check out this policy proposal put forward by a group of 10 moderate Democrats in the House a few weeks ago.

Young, healthy people wouldn’t need to buy insurance anymore without a mandate, so a lot of them probably wouldn’t, and they’d save money. That hurts older, less healthy people in the individual market, but it helps those younger folks.

The threshold is a majority of senators voting, so it could conceivably be less than 51. But don’t bet on this.

Yep. There’s no reason Republicans couldn’t regroup and try to pass something again in August.

One BCRA-sized skinny repeal. Because 100 of anything is terrifying.

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