Congress Agrees on Pretty Much Nothing When It Comes to Healthcare. We Can Work with That. (Part 2)


In Part 1 we talked about everything the Senate has been doing on healthcare during their alleged vacation. Now we turn to the House of Representatives. It seems so long ago, but the House did pass a repeal and replace bill, the American Health Care Act (AHCA), back in May. So what happens to that bill now? Nothing, actually. Since the Senate failed to pass their version of the bill, the AHCA dies on the vine. That’s not to say the House couldn’t try to bring it back at some point, but right now they’re focused on other strategies, not to mention the threat of a government shutdown and the possibility that the United States government will default on its debt.

Like the Senate, the House will be focused on keeping the government running and raising the debt ceiling.

By September 30, Congress must either pass a spending bill or a continuing resolution (legislation that authorizes short-term funding to keep the government running and extends the deadline for passing a final spending bill). If they don’t, the government will shut down as of October 1 (the start of the 2018 federal fiscal year) and all nonessential employees will be sent home. (In case it’s not clear, Members of Congress are considered essential.)

President Trump says he’ll veto any spending bill that doesn’t include funding to build a wall between the U.S. and Mexico, and will allow the government to shut down in the process. Speaker of the House Paul Ryan seems unconcerned.  During a news conference on tax reform, Ryan said no one wants a shutdown, noting that the House already passed a spending bill at the end of July that included funding to start construction of the wall. The thing is, every Senate Democrat and several Senate Republicans oppose the provision for funding a border wall—the Senate is never going to pass that bill. Even before the president’s threat, Goldman Sachs told its investors that the odds of a shutdown were 50/50. Since then, Vanity Fair has reported that the odds of a shutdown are 75%, citing a “top G.O.P. source” and quoting that source as saying, “the peculiar part is that almost everyone I talk to on the hill agrees that it is more likely than not.”

Right now it would be easy to view the existence of all these factions in both the House and the Senate, as well as the debates over the spending bill and debt ceiling, as a recipe for chaos and non-action. But there are opportunities here, in the bipartisan efforts in both chambers and in the introduction of single payer as a serious topic of discussion.

Separate from the issue of the shutdown, both the Congressional Budget Office and the Bipartisan Policy Center estimate the United States will hit the debt ceiling in early to mid-October. If Congress doesn’t vote to raise the debt ceiling before then, the United States Treasury will run out of money and will be unable to pay its bills, including what it owes to “bondholders, Social Security recipients, welfare recipients, companies that provide equipment to our military, [and] people and businesses awaiting IRS tax refunds.” (Source: Washington Post) A default would set off chaos in the stock market, trash the country’s credit rating and make it much costlier for the government to borrow money in the future. It would be gradual, but eventually we’d probably slide into recession.

Luckily, many feel that a default is highly unlikely. Greg Valliere, Chief Political Strategist for Horizon investments, a major investment management firm, has put the odds of a U.S. government default at only 5%. Treasury Secretary Steven Mnuchin and Speaker Ryan both have said that the debt ceiling will be raised in time to avert catastrophe. (Mnuchin said he is “100% confident.”)

As a former banker and hedge fund CEO, Mnuchin probably understands the risk associated with the debt ceiling better than many in Trump’s inner circle. He has been sending a consistent message to Congress that the only responsible thing for them to do is introduce a “clean bill”—that is, a bill that does nothing other than raise the debt ceiling. At the same time, though, Mick Mulvaney, the federal budget director, reportedly has implied that Conservative lawmakers should use the debt ceiling as a bargaining chip and threaten to vote no on an increase unless the bill also includes the spending cuts they want. And in fact, the Conservative House Freedom Caucus (of which Mick Mulvaney was a founding member) has said outright that they won’t vote to raise the debt ceiling unless there are deep cuts to entitlement spending—and, as we’ll see below, one of their main targets is healthcare.

All of this is happening while insurers are making their final decisions about whether to participate in the marketplace. Currently, every county in the country has at least one insurer that has said they will participate in the marketplace, but contracts don’t have to be signed until September 27. We can only hope that insurers will follow through on their commitments even if Congress doesn’t find time to pass legislation to stabilize the individual insurance market for the 2018 enrollment period.

There’s a strong move toward bipartisanship in the House.

The bipartisan Problem Solvers Caucus has introduced a plan to stabilize the individual insurance market, including by protecting cost-sharing reduction payments to insurance companies. These are subsidies that allow insurance companies to reduce costs for lower and moderate income people who aren’t eligible for Medicaid. Trump has threatened to eliminate these payments, calling them “bailouts” to insurers. (Given the actual function of these payments, that characterization is 100% inaccurate.) According to the Congressional Budget Office (CBO), ending the payments would cause spikes in premiums and a soaring increase in the federal deficit. (This overview of the CBO estimate from the New York Times is helpful for understanding the details.)

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The 40+ members of the Problem Solvers Caucus, which is co-chaired by Republican Tom Reed of New York and Democrat Josh Gottheimer of New Jersey, have agreed to vote as a block once they have reached agreement on the issues (and by agreement they mean three-quarters of the Caucus members). However, it remains to be seen whether this approach will produce progress or gridlock once the group begins to negotiate the finer points of its plan.

Meanwhile House Conservatives are playing both sides of the fence.

The Freedom Caucus is attempting to resurrect a repeal bill while also working on legislation to stabilize the individual insurance markets before the 2018 enrollment period starts.

Several members of the Caucus launched a petition on August 11, seeking to move a “clean repeal” bill (i.e., repeal the Affordable Care Act without replacing it) onto the floor for a vote, using parliamentary procedure to bypass committee hearings. If a simple majority of House members sign the petition (218 in total), the House will vote. (Incidentally, the bill is identical to one that passed the House in 2015—this gives the Caucus leverage to shame their colleagues who voted for it in 2015 but who might be reluctant to do so now.)

At the same time, the Chair of the Freedom Caucus, Mark Meadows of North Carolina, is working with Tom MacArthur of New Jersey to draft legislation to stabilize the individual market. Like the Problem Solvers’ plan, the Meadows-MacArthur plan would authorize cost-sharing reduction (CSR) payments to insurance companies. However, the Meadows-MacArthur plan would also allow more flexibility to states in the existing Section 1332 waiver process. Officially called “State Innovation Waivers,” they allow a state to bypass certain key requirements of the ACA if the state proves that under its innovative approach, the people in that state get at least as good coverage as they would under the full requirements of the ACA (Source: CMS). The concern about the MacArthur-Meadows plan is that it will loosen up the waivers so much that states might be able to cut back on services, limit eligibility, or otherwise reduce coverage from current levels. After all, these same two Congressmen also wrote the amendment to the AHCA that allows states to waive coverage for essential benefits and charge higher premiums to people with preexisting conditions.

John Conyers is dusting off a 14-year-old single payer bill. House Democrats are into it, but are they accomplishing anything by introducing it?

Democrat John Conyers of Michigan has already reintroduced his own Medicare for All bill. Conyers has been introducing this bill regularly since 2003, but for the first time a majority of House Democrats have actually signed on. Unlike in the Senate, however, no one in the House has said they will introduce a bill that would put us on an incremental path toward single payer. In all likelihood, Conyers and the other Democrats supporting his bill will be making a largely symbolic gesture that won’t necessarily serve to open up a meaningful discussion of single payer as a legitimate option now or in the future.


Congratulations, you’ve made it through both chambers of Congress! Right now it would be easy to view the existence of all these factions in both the House and the Senate, as well as the debates over the spending bill and debt ceiling, as a recipe for chaos and non-action. But there are opportunities here, in the bipartisan efforts in both chambers and in the introduction of single payer as a serious topic of discussion, at least in the Senate, in the media, and among the general public, if not fully in the House.

When you start calling your Senators and Representatives next week, there will be a lot vying for their attention other than healthcare. It will be the job of advocates to keep reminding them that the calendar doesn’t stop and that certainty in the insurance market will be critical to a successful enrollment period for 2018.

While we wait for Congress to return, you can help build a community of health equity advocates by starting the conversation right now! Share your thoughts by commenting below, or on Facebook or Twitter.

  • Is there anything missing from this recap that you think will influence the healthcare debate going forward?
  • Where do you think the greatest threats and opportunities lie?
  • Is there something you would like to know more about?

See you again soon on the #stairwaytohealthcare. Until then, keep climbing!

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