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The Health 202: Mollifying conservatives on health care is harder than satisfying moderates


Sen. Ted Cruz (R-Tex.) sits in the East Room of the White House. (AP Photo/Carolyn Kaster)

Enticing conservatives to vote for his Obamacare overhaul is Senate Majority Leader Mitch McConnell’s (R-Ky.) biggest legislative conundrum right now. Revising the bill to attract moderates is a relatively simple chore; he would just need to expand its spending so fewer Americans lose coverage under it. But there are far fewer levers at McConnell’s disposal for attracting a half dozen conservative senators who want even more of the Affordable Care Act wiped out.

McConnell’s Better Care Reconciliation Act already makes some pretty big dents in the existing health-care law. The Senate bill would repeal the ACA’s individual mandate to buy coverage, the employer mandate to offer it to workers and nearly all of its taxes. It would also phase out ACA’s Medicaid expansion, pare down its federal subsidies for buying private plans and give states more leeway in how they could run their marketplaces in alternative ways.

All that wasn’t enough for Sens. Rand Paul of Kentucky, Mike Lee of Utah, Ted Cruz of Texas and Ron Johnson of Wisconsin, who are demanding that the Senate bill carve an even bigger hole out of the ACA before they’ll vote for it. They’re rallying around an amendment from Cruz which would lift even more ACA regulations off insurers — including its requirement to cover people with preexisting conditions and charge them the same premiums as healthy people.

Yesterday, Cruz told the McAllen, Texas Monitor that his vote “depends what’s in it." "I believe it is critical that we honor our promise to repeal Obamacare," Cruz said — even as he faced protesters trying to yell over his speech at an Independence Day ceremony who oppose the effort to ditch much of the law.

Cruz supporters were also at his speech, but the protestors were louder, Texas Tribune reporter Patrick Svitek tweeted:

At least for now, @TedCruz stops short of working the part of the crowd that appears to have the most vocal protesters.

— Patrick Svitek (@PatrickSvitek) July 4, 2017

Some attendees showed their emotion through some pretty extreme statements:

"Ted wants us dead." @TedCruz gets an earful from protesters while celebrating July 4 in Dem stronghold of McAllen:

— Patrick Svitek (@PatrickSvitek) July 4, 2017

Things calmed down a bit as Cruz rode through McAllen in a parade:

"Isn’t freedom wonderful?" Cruz said onstage, according to the Texas Tribune. "Think about it: In much of the world, if protesters showed up, they would face violent government oppression. In America, we’ve got something different."

Cruz referenced the protesters again near the end of his speech, calling them "our friends who are so energized today that they believe that yelling is a wonderful thing to do."

But there’s a big, outstanding question as to whether McConnell can satisfy the demands from Cruz and co. to move the bill in a rightward direction. Because BCRA is a budget reconciliation bill, everything in it must affect federal spending, as determined by the Senate parliamentarian. While adding in more federal assistance (which moderates want) obviously affects federal spending, it’s not so clear whether easing regulations does, making it a harder task for McConnell to modify the bill in a way that appeals to conservatives.

Privately, McConnell doesn’t even want to give insurers full opt-out from the ACA’s regulations because they’re intended to protect patients who could otherwise be denied coverage or charged a lot more for it. The protections for patients with preexisting conditions are a popular part of the ACA and removing them could alienate moderates.

But McConnell can’t afford to lose the whole Paul/Cruz/Lee/Johnson contingent if he wants to pass the bill, so last week he shipped his health-care legislation back to the Congressional Budget Office for a second round of analysis. This time, the CBO is evaluating several potential changes to the measure, including changing its Medicaid growth rate, providing more funding for opioid abuse prevention — and tacking on the Cruz amendment, which would allow states to opt insurers out of ACA regulations as long as they offered just one plan that’s compliant.

Sen. Ron Johnson (R-Wis) (AP Photo/Steve Helber)

If McConnell added that Cruz amendment to the Senate health-care bill — and it’s not at all clear that he will — it would likely secure the support of Cruz/Lee/Johnson, and possibly Paul as well.

Johnson complained in a New York Times op-ed last week that the Senate bill "leaves in place the pre-existing-condition rules that drive up the cost of insurance for everyone." "Instead, we should return more flexibility to states, to give individuals the freedom and choice to buy plans they want without Obamacare’s ‘reform,’" Johnson wrote.

Johnson has even called the preexisting condition protections a "new entitlement," NYT’s Margot Sanger-Katz noted:

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SIGN UP NOW Kellyanne Conway, counselor to President Trump. (Photo by Jabin Botsford/The Washington Post)

AHH: The White House is maintaining a confident front on the health-care issue, the strong undercurrents notwithstanding. White House counselor Kellyanne Conway told Fox & Friends on Monday that she was “very hopeful, very confident” that Trump would have legislation on his desk this summer.

But Politico’s Sarah Karlin-Smith tweeted the reality — Republicans from White House legislative affairs director Marc Short to Sen. Paul to President Trump to Health and Human Services Secretary Tom Price are giving mixed messages about progress on the measure:

Sen. Susan Collins (R-Maine) made her traditional visit to the Fourth of July parade in Eastport, Maine. (Murray Carpenter for The Washington Post)

OOF: But here’s a factor jeopardizing the Senate’s ability to pass a health-care bill. Cruz is one of a number of Republicans are spending the Fourth of July recess fending off protesters, low poll numbers and newspaper front pages that warn of shuttered hospitals and 22 million people being shunted off their insurance, my colleague Dave Weigel reports.

One of them was Sen. Susan Collins of Maine, who spent yesterday marching through Eastport as constituents cheered — and then asked whether she would vote against repealing the Affordable Care Act. Collins has said she opposes the Senate bill without some major changes to it.

“There was only one issue. That’s unusual. It’s usually a wide range of issues,” Collins said in an interview after the parade. “I heard, over and over again, encouragement for my stand against the current version of the Senate and House health-care bills. People were thanking me, over and over again. ‘Thank you, Susan!’ ‘Stay strong, Susan!’ ”

"Few Republicans have responded like Collins, who let voters know where to find her," Dave writes. "Last month, when Congress broke for the long holiday, just four of the Senate’s 52 Republicans — Collins, Sen. Ted Cruz (R-Tex.), Sen. Dean Heller (R-Nev.), and Sen. Lisa Murkowski (R-Alaska) — announced appearances at Fourth of July parades. Just three — Cruz, Sen. Jerry Moran (R-Kan.) and Sen. Bill Cassidy (R-La.) — said they would hold public town hall meetings…Since the repeal debate began, protesters have made direct confrontations with elected officials a central part of their opposition to the Republican bill — copying what worked for tea party activists, who packed Democratic town halls during the lengthy 2009-2010 Affordable Care Act debate."

The State Capitol building in Charleston, West Virginia. (Photo by Michael S. Williamson/The Washington Post)

OUCH: Residents of West Virginia, Kentucky and Arkansas stand to see the biggest increase in uninsured rate under the Senate health-care bill. View how each state would be affected with this cool graphic from The Post’s Kim Soffen.

Aubrey Pratt, 5, holds a sign with his mother and brother at a rally against the GOP health care bill at Harbor-UCLA Medical Center in California. (AP Photo/Reed Saxon)

–Democrats home for the July Fourth recess also heard from constituents who don’t want Obamacare repealed. California Sen. Kamala Harris spoke Monday with hundreds of activist at a rally at Harbor-UCLA Medical Center, per LA Times columnist Cathleen Decker:

"What I say is don’t take our stuff. Leave my stuff alone," Harris said, according to a report by local station KABC. "It’s not like we left our health care on the bus or at the club or in an Uber. This is not about losing something. They’re trying to take our health care.”

Harris tweeted about it too:

—-Politico reporter Dan Diamond had a good tweet thread over the weekend showing hometown newspapers of lawmakers key to the health-care debate. Here are a few of the front pages:

From the Houston Chronicle in Texas:

From The Dominion Post in West Virginia:

From the Lexington Herald-Leader in Kentucky:

A few more good reads from the Web around the effort to overhaul Obamacare:

Here’s a Post fact-check on a video from the White House explaining Obamacare’s failures:

–Here’s something Pope Francis and President Trump agree on: The parents of a terminally ill baby should be allowed to seek more medical care instead of being taken off life support. Trump tweeted this on Monday, following a tweet from the pope:

The tweets were referring to Charlie Gard, an infant with a rare genetic condition and resulting brain damage that has robbed him of his ability to move his arms and legs, eat or even breathe on his own. The European Court of Human Rights declined to hear the matter last week, upholding previous court rulings that it was in Charlie’s best interest to withdraw life support against his parents’ wishes.

"His story swept the globe as his parents, Chris Gard and Connie Yates, expressed their devastation that they had no say in their young son’s life or how, when or where their son would die," my colleague Lindsey Bever reports. "They appeared on video last week, sobbing and saying that Charlie would be removed from life support Friday and would take his last breaths at the hospital."

"Charlie was born in August with a rare genetic condition called infantile-onset encephalomyopathic mitochondrial DNA depletion syndrome," Lindsey continues. "Weeks after birth, Charlie was struggling to hold up his head and was not gaining weight. At the two-month mark, he had become lethargic, and his breathing had become shallow…Earlier this year, doctors concluded that nothing more could be done for the terminally ill infant. Charlie’s parents pushed back, arguing that there was an experimental treatment in the United States."

A Twitter handle created to support Charlie tweeted thanks to the president:

(AP Photo/J. Scott Applewhite)

  • The American Enterprise Institute will hold an event on health savings accounts on Thursday.
  • The National Academy of Medicine will hold an event on “Opportunities for Improving Outcomes, Value, and Health” on Thursday.
  • The Bipartisan Policy Center is holding an event on solutions to long-term care financing on July 11.
  • The Hill is hosting an event on "The Cost of Caring: Family Caregivers and Tax Reform," featuring Sen. Tammy Baldwin (D-Wis.), Sen. Joni Ernst (R-Iowa), Rep. Dan Donovan (R-N.Y.) and Rep. Michelle Lujan Grisham (D-N.M.) on July 13.

Sen. Mike Lee (R-Utah) says health-care bill ‘leaves out the forgotten man and woman’:

The lengthy legal battle over Charlie Gard:

Trump celebrates Independence Day with military families:

Trump says he has never heard the term ‘second lady’: