« Wat is happening? »
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:
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.
