Voter in Maine voted to expand Medicaid under the Affordable Care Act during Tuesday's elections.
The move could be a signal of more ballot measures to expand Medicaid in various states.
It also appears to be an indication of the growing popularity of Obamacare's various provisions.
On Tuesday night, a significant majority of Maine voters decided that after years of false starts and stonewalls from their governor, they wanted to see Medicaid expanded in their state.
Fifty-nine percent of Maine voters supported a ballot measure that would expand Medicaid under the Affordable Care Act (ACA), the law also known as Obamacare.
The move came after Republican Gov. Paul LePage blocked the expansion of Medicaid five different times over the past few years and will give healthcare access to as many as 80,000 low-income Mainers.
LePage is using a procedural tactic to slow roll the expansion's implementation, due to what he says are concerns about the cost of the measure. But it's clear that Maine is closer than ever to making the program a reality.
Maine's vote is the first time that a state has used a ballot measure in order to expand Medicaid under the ACA. It might catch on across the country.
"The Maine ballot initiative is likely to have ripple effects across the country," said Diane Rowland, executive vice president at Kaiser Family Foundation, a nonpartisan health policy think tank.
A quick Medicaid expansion refresher
Obamacare allows states to increase the limit on people that qualify for Medicaid to 138% of the federal poverty level.
The ACA mandated that all states expand the program, but the Supreme Court ruled in 2012 that states could decide whether to undertake the expansion on an individual basis.
Most of the cost is covered by the federal government. For instance, in Maine, the Office of Fiscal and Program Review estimated that the federal government would pay $525 million for the expansion while the cost to Maine would be just over $55 million a year.
Given the success of the Maine vote, it seems that more measures to expand Medicaid in the remaining 18 states could be on the way.
Rowland pointed to places like Utah, where signatures for a ballot measure could soon be collected for a vote in 2018. According to an analysis from the Urban Institute, 315,000 people in Utah would be eligible for Medicaid if it is expanded there. Advocates in Idaho are also trying to get a similar measure to voters next year.
Timothy Jost, a law professor emeritus at Washington and Lee University in Virginia and a supporter of the Affordable Care Act, said that Virginia could be next after Tuesday's elections could end up swinging control of the state legislature to Democrats.
"With the Democrats having picked up 16 seats in the Virginia House of Delegates and the governorship, it will definitely be on the agenda in Virginia," Jost said. (Democratic control is up in the air pending the outcomes of recounts in four races.)
Democrats control the governorship and appear to have picked up at least enough seats to split control of the state's lower legislative chamber. Republicans still hold the Virginia state Senate, but only by a single seat.
"I think the successful outcome in Maine will inspire action in other states in the wake of the ACA repeal and replace loss in the US Senate and as the expansion states continue to show declines in the uninsured rate, and positive impacts on coverage and state economies," Rowland told Business Insider.
Voters are warming up to Obamacare
The decisive victory in Maine also appears to reflect a growing trend towards accepting several key tenets of the ACA.
Research has shown that states that have expanded the program have exhibited lower premiums in the Obamacare marketplaces and a larger overall decline in the uninsured rate. Jost said that would lead to more state-level lawmakers and voters warming up to the idea.
"States that are able to consider the issue simply from a practical financial, as well as a humanitarian, perspective, as opposed to a strictly ideological perspective, must realize that it makes no sense to continue not expanding Medicaid," he told Business Insider.
More broadly, the vote is another in a slew of data points that show a growing acceptance of the ACA as Republicans have tried to dismantle the law.
Meanwhile, exit polls from Virginia on Tuesday night showed that 40% of voters considered healthcare the biggest factor in their vote. Of those voters, 77% voted for the Democrat Ralph Northam, who favors the expansion.
Matthew Fiedler, a fellow at the Brookings Institutions' Center for Health Policy, said the Maine result showed that Americans want to maintain the higher levels of insurance coverage that came with the ACA.
"I think last night’s result in Maine helps illustrate the fundamental problem Republicans have faced throughout the ACA repeal debate," Fiedler told Business Insider. "Most of the ACA repeal bills have been built around proposals, that would significantly reduce insurance coverage. But both polling data on the various repeal bills and last night’s results suggest much of the public is not comfortable with that outcome and, in fact, would prefer to move in the opposite direction."
House Republicans want to move their giant tax bill out of the Ways and Means Committee on Thursday.
The bill can only add $1.5 trillion to the deficit over the next 10 years, but the current version adds $74 billion more than that.
Republicans have a few options to fill this gap, including a major change to Obamacare.
House Republicans are trying to figure out how to fill a $74 billion hole on Thursday as they make last-minute edits to their sweeping tax overhaul legislation, the Tax Cuts and Jobs Act (TCJA).
Republicans are attempting to pass their tax overhaul using a process known as budget reconciliation. But in addition to allowing Republicans to pass the bill in the Senate with only Republican votes, it also means the bill must to abide by certain rules.
The original legislation released November 2 fit into this window, but an amendment added Monday by the bill's author — Ways and Means Committee Chair Kevin Brady — pushed the deficit load higher than the allotment.
The amendment adopted Monday made a change to a proposed 20% excise tax on multinational companies' profit movement after an uproar from industry groups. The Joint Committee on Taxation determined that the provision would bring in just $6.5 billion over the next 10 years, down from the original $154.5 billion.
Other provisions in Brady's amendment meant the bill would add around $1.574 trillion in debt over the decade-long window, according to the JCT — thus, the $74 billion hole.
To fix the issue, Brady is expected to introduce what is known as a manager's amendment — a last-second slew of proposed changes to bill that would in theory bring it under the $1.5 trillion threshold.
One of the most controversial possibilities by which Brady could seek to raise new revenue would be the inclusion of a repeal of the Affordable Care Act's individual mandate. While this would eliminate the tax penalty for declining to purchase health coverage, a report Wednesday from the Congressional Budget Office showed it would lead to 13 million more people going without insurance over the next 10 years compared to the current system.
By lowering the number of people on the Obamacare exchanges, the government would pay out less in subsidies to help people pay insurance premiums. In the end, the CBO estimated this would add $338 billion in new revenue, which would more than fill the gap in the legislation.
Brady has been noncommittal about including the mandate repeal.
The Ways and Means Committee kicked off their last day of consideration of the TCJA on Thursday, and the bill is expected to be approved by the group sometime around noon.
The number of ObamaCare sign-ups during the first week of enrollment has doubled since last year, setting a new record high.
President Donald Trump has previously made various cuts to subsidies and outreach funding and has shortened the enrollment period in an effort to "repeal" ObamaCare on his own.
So far, his efforts seem to have been ineffective.
Obamacare sign-ups in the first few days of the open enrollment period this year have far outpaced those during the same period in previous years, and despite President Donald Trump's efforts to diminish the enrollment period and slash outreach, the number of sign-ups during the period this year has set a new record.
The number of people signing up on HealthCare.gov in the first week of enrollment is "roughly double" what it was in previous years, a source told Politico. On November 1 alone, which was the first day of the enrollment period, 200,000 signed up for a 2018 plan, which itself was double the amount of first-day sign-ups last year according to The Hill.
The Department of Health and Human Services released its official numbers on Thursday, showing that 601,462 people signed up for plans between November 1 and November 4. Of those, 137,322 were new consumers.
While the department did not provide an exact comparison to last year's pace of sign-ups over four days, the initial sign-ups did exceed the weekly pace of enrollment of the first month in 2016.
Trump has been railing against Obamacare since he was a presidential candidate
These high numbers come after efforts by the Trump administration to limit the number of people signing up, including shrinking the enrollment window and dramatically cutting funding for sign-up assistance and advertising for the program. The president has repeatedly said he wants to end Obamacare, formally known as the Affordable Care Act, with or without Congress, and after several unsuccessful efforts to repeal the law this year, Trump said he is willing to do it himself.
"I just keep hearing repeal-replace, repeal-replace," Trump said in October. "Well, we're starting that process."
Trump has also abandoned health care subsidies that would have allowed low-income patients to make out-of-pocket payments more easily and is reportedly planning an executive order that will scrap the individual mandate portion of the Affordable Care Act.
These and other steps initially led analysts at Standard & Poor's to estimate that up to 1.6 million fewer Americans would sign up on HealthCare.gov than last year. In addition, despite Trump's repeal of healthcare subsidies, which many believed would lead to premium spikes, around 80% of Obamacare recipients qualify for premium assistance under the program, meaning that the subsidy repeal would have little effect on the healthcare program, according to Politico.
Reportedly, state-based exchanges are also seeing higher-than-expected enrollment. While it remains unclear if this record pattern of enrollments will continue until the sign-up period closes on December 15, fears that Trump's executive level cuts would decimate Obamacare appear to be largely unsubstantiated so far.
Senate Republicans are set to include the repeal of a key part of Obamacare in their tax bill to raise revenue.
The idea has the support of top Republican senators and President Donald Trump.
It could prompt opposition from moderate GOP senators since it could lead to 13 million more people going without health insurance.
Even as Republicans embark on their attempt to overhaul the federal tax code, the fight over the future of the Affordable Care Act is again coming to the forefront.
Senate Republican leaders on Tuesday said the massive tax bill in the chamber would include the repeal of a key part of the healthcare law to free up more money for tax cuts.
Senate Majority Leader Mitch McConnell told reporters Tuesday that it would be "helpful" to include the repeal of Obamacare's individual mandate in the tax bill, the Tax Cuts and Jobs Act (TCJA).
Other members of GOP leadership, Sens. John Thune and John Cornyn, also told reporters that the mandate repeal would be included in the bill.
Senate Finance Committee Chair Sen. Orrin Hatch, who crafted the Senate's TCJA, told reporters Tuesday that the mandate's repeal was still on the table. During a hearing on the legislation, Hatch told committee members that the mandate repeal was not in the current version of the bill but demurred on whether it would be included a later version.
Adding the healthcare fight into the tax bill mix adds another political complication to an already volatile process.
The individual mandate, which imposes a penalty on people who go without health insurance, is a key part of the Affordable Care Act, or Obamacare. According toa recent analysis from the Congressional Budget Office, repealing the mandate would reduce the federal deficit by $338 billion over 10 years.
The savings, according to the CBO, would come from 13 million more people going without health insurance compared to the current baseline. By eliminating the mandate, healthy people would likely drop out of the Obamacare exchanges leading to a sicker group of enrollees and higher costs. As costs rise, more and more people would be priced out of the market, causing the uninsured rate to increase.
The developments Tuesday came few hours after Sen. Rand Paul said he would offer an amendment to the bill to include the mandate repeal.
"Today I am announcing my intention to amend the Senate tax bill to repeal the individual mandate and provide bigger tax cuts for middle income taxpayers," Paul tweeted. "The mandate repeal is a promise we all made and we should keep. It also allows an additional $300 billion+ in tax cuts."
Mandate repeal has become a rallying cry for Senate conservatives — and Trump
The Obamacare individual mandate repeal has become a point of emphasis for many conservative GOP members in the debate over the TCJA.
Sens. Ted Cruz and Tom Cotton have both advocated for the mandate repeal to be part of the tax bill.
"Now, how about ending the unfair & highly unpopular Indiv Mandate in OCare & reducing taxes even further? Cut top rate to 35% w/all of the rest going to middle income cuts?"Trump tweeted.
The move risks losing votes of moderate Republicans
But including the mandate repeal runs the risk of losing more moderate votes, like GOP Sens. Lisa Murkowski and Susan Collins. They helped block earlier efforts to repeal and replace Obamacare, in part because they felt the attempts would leave too many people without coverage.
According to Bloomberg's Steven Dennis, Collins said including the mandate repeal would end any chance of getting Democratic votes for the TCJA. She said she worried that the repeal would increase insurance premiums.
Senate Minority Leader Chuck Schumer said the move proved that Republicans "are doubling down on the same partisan strategy that would throw our health care system into chaos."
"If the American people weren’t already outraged by this bill," he said, "injecting healthcare into it will certainly do the trick."
Republicans have hastily moved their tax bill, the Tax Cuts and Jobs Act, through the House and nearly through the Senate.
The speed of the battle has caused analysts to raise expectations for passage.
It has also cracked open even more serious divisions between the GOP and Democrats.
In just two weeks, Republicans in the House were able to introduce their massive tax bill, get it through the tax-writing committee, and pass it through the full chamber.
Similarly, the Senate has moved its version of the Tax Cuts and Jobs Act out of the Finance Committee just a week after its introduction.
The unusual speed of this legislative push is raising expectations among analysts and Wall Street economists for the bill's chances of passing. It is also creating distinct fault lines on Capitol Hill.
Republicans say that the speed is the culmination of years of effort and is necessary to ensure tax cuts come as quickly as possible. Democrats argue that the speed is being pursued by the GOP to get a legislative win on a bill they believe doesn't meet muster.
Need for speed
The simplest explanation for the GOP's speed on the legislation: Republicans have promised to get it done by the end of the year. President Donald Trump has been adamant that the bill be on his desk "by Christmas." Republicans are following a pace that meets that self-imposed deadline.
Chris Krueger, an analyst at Cowen Washington Research Group, said the sudden speed of the tax bill also had a political necessity: Republicans need a win. After a series of electoral missteps and concerns over the special Senate election in Alabama, the party — and Trump — needs a victory it can point to ahead of the 2018 midterms.
Writing in a note to clients, Krueger said that since the Alabama Senate chaos and the recent Democratic electoral gains in Virginia and New Jersey, congressional Republicans were "in a full-blown hurry-up offense" he said was characterized by "no amendments, closed rules, rigid party discipline, and very little understanding of the legislation."
Things are looking up for the tax bill
The fast-track effort and its relative success over the past few weeks have analysts starting to believe the GOP can get a tax bill to Trump's desk.
Alec Phillips, a political economist at Goldman Sachs, recently raised his chances of a tax bill passing soon because of how quickly the bill had advanced through the House and Senate committees.
"The tax reform debate is moving forward faster than we or most other observers expected," Phillips wrote Tuesday. "While there are a number of issues that could still slow it down, or stop it altogether, we believe the odds that tax reform will be enacted by early 2018 — already our base case — have risen to 80% (from 65% previously)."
Krueger echoed that sentiment, saying the speed and relative ease with which the legislation had moved left the GOP in a better position.
"The tax process is much further down field than we ever anticipated — particularly on the Senate-side," the analyst said. "This has probably been the best 10-day policy stretch for Congressional Republicans all year."
Fast track or years in the making?
Democrats have complained throughout the markups in both the House Ways and Means and Senate Finance committees that they were not allowed enough time to study the bill and the potential impact of various provisions.
"Reforming the entire tax code in a matter of weeks is insanity," a senior Democratic aide told Business Insider on Wednesday. "Today in the Finance Committee, Democrats are considering a bill that was released last night. Last night. Tomorrow, the Committee will vote yes or no, less than 48 hours after the bill came out."
While Democrats have grumbled about the lack of hearings, Republicans have argued that the bill has emerged from years of hearings on various proposed changes to the tax code.
"These policies have been debated and vetted for quite some time now," a GOP aide told Business Insider. "The current effort in Congress is simply taking the groundwork that was laid and turning it into action."
Senate Finance Committee Chair Orrin Hatch and other GOP leaders have pointed to numerous hearings on general tax proposals that studied how various types of cuts would affect the economy. Democrats note that those hearings did not pertain to the particular legislation at hand.
Don Stewart, a spokesman for Senate Majority Leader Mitch McConnell, said Democratic objections were mostly designed to slow down the pace of the bill and delay any tax reform until 2018.
"Of course it's an attempt to delay tax relief for next year," Stewart told Business Insider. "If 70 hearings aren't enough, I'm not sure what to say."
Comparisons to Obamacare and the Reagan tax cuts
But to Democrats, the speedy process stands in direct contrast to tax cuts enacted under President Ronald Reagan. Republicans point to the age of that 1986 legislation — the most recent major overhaul of the federal tax code — as a reason new reforms need to be enacted. But Democrats say today's process in nothing like those negotiations.
"President Reagan's 1986 reform took two years, but Republicans know that their bill can't withstand that much public scrutiny so they’ve got to rush it though," one senior Democratic aide said.
Republicans say their tactics on tax reform are at the very least no worse than the debate over the Affordable Care Act, or Obamacare, which passed through a Democratic-controlled Congress in 2010.
"We've heard criticisms from a former majority in this very room moved through the Affordable Care Act and then Speaker Pelosi said, 'This is the bill we have to pass so you know what's in it,'" GOP Rep. Peter Roskam said during the markup of the tax bill in the Ways and Means Committee. "So the sanctimonious, self-righteous, retroactive nostalgia about process, I think we can dismiss."
Democrats counter that the ACA was debated for more than three months after the initial text of the legislation was released before it got its first House vote, and amendments offered by Republicans were added to the bill.
A Senate slowdown
It appears that the only thing that could slow down the Tax Cuts and Jobs Act's progress is the Republican Party itself. Based on recent developments in the Senate, that could happen.
Sen. Ron Johnson of Wisconsin came out Wednesday as the first party member to publicly defect on the tax bill. At least five other members have concerns on various aspects of the bill.
Trying to address all of these concerns while still ensuring that the bill qualifies under Senate rules could be difficult, particularly because one of Johnson's major concerns was the speed of the process.
Slowing the bill down, even a little, to satisfy some members could hamper its chances, given the looming deadlines ahead for Congress over government funding, immigration legislation, and more.
"Until 50 Republican Senators can agree on anything other than judges," Cowen's Krueger said Friday, "we will remain on our lonely island that believes the Congressional GOP will fail on taxes."
Alaska Sen. Lisa Murkowski said that she supported the repeal of Obamacare's individual mandate as part of the GOP's tax plan.
This is a positive for the tax bill, as there were concerns over Murkowski's support amid proposed changes to the Affordable Care Act.
Despite the support, there's no guarantee the mandate repeal ends up in the final bill.
Alaska Sen. Lisa Murkowski, one of the handful of Republican senators who are question marks to support the GOP's massive tax code overhaul, gave a big boost to the plan on Tuesday.
"I believe that the federal government should not force anyone to buy something they do not wish to buy in order to avoid being taxed," Murkowski wrote. "That is the fundamental reason why I opposed the Affordable Care Act from its inception and also why I cosponsored a bill to repeal the individual mandate tax penalty starting as early as 2013."
The Alaska senator previously helped block Republican efforts to repeal and replace Obamacare over the summer. She cited the potential negative effects on the Medicaid program, insurance coverage, and Planned Parenthood.
Murkowski's opposition drew concern that she could decline to support the TCJA due to the mandate repeal. According to an analysis by the Congressional Budget Office, 13 million more people would be without health insurance in 2027 compared to the current baseline if the mandate is repealed.
Murkowski, however, differentiated between Medicaid cuts in the previous Obamacare replacement bills and the mandate repeal.
"It is important to emphasize that eliminating this tax penalty does not take care away from anyone," the senator wrote. "Instead, it provides important relief to those who have been penalized for choosing not to buy unaffordable insurance."
At the same time, while the mandate appears to not be a deal-breaker for Murkowski, it doesn't mean her vote is guaranteed. The senator did not explicitly endorse the tax legislation in her op-ed, and she called for the bipartisan insurance market stabilization bill from GOP Sen. Lamar Alexander and Democratic Sen. Patty Murray to be passed in conjunction.
Other on-the-fence GOP senators, such as Sen. Susan Collins of Maine, could also balk at the mandate repeal's inclusion. The Trump administration has not made the mandate repeal a red line. Mick Mulvaney, the director of the Office of Management and Budget, suggested last weekend that the White House would be fine with removing the provision from the tax legislation if it overly complicated the political logistics.
The number of people enrolling in Obamacare insurance plans through the first three weeks of the sign-up period is higher than the number of people who signed up through four weeks in 2016.
While the pace if enrollment is higher than last year, the enrollment period is just six weeks instead of 12.
That means that the total number of sign ups could still be substantially lower than 2016, a worrying sign for the future of the individual insurance market.
Enrollment in the Affordable Care Act's federally funded insurance marketplace is crushing last year's pace, according to a new report, but the long-term outlook remains more complicated.
An enrollment snapshot released Wednesday from the Department and Health and Human Services (HHS) and Centers for Medicare and Medicaid Services (CMS) showed that enrollments in healthcare plans through the federally funded Healthcare.gov exchange has paced well ahead of last year.
Through November 18, 2,277,079 people enrolled in a Healthcare.gov plan. Of those, 566,042 are new customers, and 1,711,037 are returning enrollees.
That's a much faster pace than last year. Through the first full month of enrollment in 2016, just 2,137,717 people had enrolled in total, and 519,492 were new enrollees.
The open-enrollment period for Healthcare.gov plans in 2017 is half the length as previous years — just six weeks — due to a rule change from the Trump administration.
When compared to the halfway mark of open enrollment in 2016, this year lags well behind. For instance, through week six of the 12-week enrollment period last year, there were 4,015,709 total selections and 1,103,507 new enrollees.
A lower pace of enrollment is likely to lead to a sicker pool of people signing up, according to health policy experts, and could undermine some of the individual insurance market's stability.
With 12 legislative days left in 2017, pressure is mounting on President Donald Trump and Republican leaders to come through with legislative wins.
This week will be defined by the Senate fight over the GOP's proposed tax-code overhaul, a necessary step to deliver a legislative victory for the GOP.
On the heels of the tax fight is a battle to avoid a government shutdown on December 8, which could also lead to a slew of policy battles on everything from healthcare to the border wall to the NSA's spying powers.
As the first calendar year of Donald Trump's presidency comes to a close, the next two weeks will be jam-packed with legislative battles that could define the administration for the rest of the term.
On the legislative docket, among other things, is the Republican push to overhaul the tax code; a government funding bill to prevent a partial shutdown; the reauthorization of the Children's Health Insurance Program; various healthcare bills; and the Deferred Action for Childhood Arrivals program.
The pile of deadlines and priorities will be difficult for Trump and congressional Republicans to navigate, as there are only 12 days left on Congress' 2017 schedule.
The bill, which cleared the Senate Finance Committee before Congress' Thanksgiving recess, is expected to be rolled out Tuesday for debate and amendments on the Senate floor. A vote is expected by the end of the week — and passage will be imperative to deliver on Trump's promise of a tax bill signed into law by the end of the year.
While Trump has been able to claim a series of regulatory and judicial wins in his first year, the president does not yet have a major legislative victory. Passing the tax legislation would serve as that victory and ease pressure on Republicans heading into the 2018 midterm elections.
"The Republican Party exists as a species to cut taxes — this is what they do," Chris Krueger, an analyst at Cowen Washington Research Group, said in a note to clients last month. "In control of the Presidency, House, and Senate for the first time since 2006, what good are they if they can't deliver on taxes? This is a bit of a derivative from the self-preservation thesis, but we hear it constantly as one more data point in the tax reform inevitability argument."
But passing the bill, even with the mounting pressure, is no guarantee. One Republican, Sen. Ron Johnson of Wisconsin, has already said he'll vote against the current iteration of the bill. Other Republicans with concerns include Sens. Susan Collins, Jeff Flake, and Bob Corker.
The push will also serve as another test of Trump's dealmaking prowess, a skill he touted in his run to the White House. The self-described "closer" was unable to help shepherd a bill to repeal and replace the Affordable Care Act through the Senate in July and September. And after public battles with many lawmakers, the tax fight could reveal the degree to which Trump holds sway over lawmakers.
Trump is expected to meet with Republicans on the Senate Finance Committee at the White House on Monday and the full GOP Senate conference on Tuesday at its weekly luncheon, with the goal of shoring up votes.
"The Tax Cut Bill is coming along very well, great support," Trump tweeted Monday. "With just a few changes, some mathematical, the middle class and job producers can get even more in actual dollars and savings and the pass through provision becomes simpler and really works well!"
Then comes the shutdown fight
On the heels of the possible Senate vote on the tax plan is a fight over government funding. The current funding legislation, signed in September after Trump made a deal with Democratic leaders, expires December 8, after which the government would go into a partial shutdown absent new legislation.
Both Democrats and Republicans are likely to try to include other legislative priorities into the funding package, most likely complicating the dynamics ahead of votes. Here's a quick list of things that could be attached to the bill:
CHIP funding: The funding for the Children's Health Insurance Program, which helps children and pregnant women access healthcare, ran out at the end of September. Some states could begin to ration care unless the program is funded this month.
DACA and the border wall: Congress has until March 5, 2018, to authorize the controversial Obama-era policy that shields from deportation nearly 800,000 young immigrants. By adding it to the shutdown bill, Democrats could pressure GOP members to support preserving the program. Trump has suggested that funding for his long-promised wall along the border with Mexico must be included on any DACA compromise.
The Alexander-Murray Obamacare-stabilization bill: The bill would extend funding for government payments to insurers and include measures designed to shore up the Obamacare markets. Despite having enough support in the Senate to pass, the bill has not been brought up by Republican leadership.
More disaster relief: The White House requested an additional $44 billion to help recovery efforts from natural disasters in Texas, Puerto Rico, Florida, and the US Virgin Islands.
Reauthorization of the Foreign Intelligence Surveillance Act: Section 702 of FISA, which allows the National Security Agency to survey communications without a warrant, expires at the end of the year.
National Flood Insurance Program: The program's authorization was kicked until December 8 but needs to be renewed. The House passed a long-term extension of the NFIP on November 14.
As Krueger said, each of these issues comes with its own difficult political calculus, so pressure on Trump and GOP leaders will be high. Democrats, on the other hand, will do their best to extract policy victories of their own in the shutdown fight.
"And it is not just one issue — any one of the issues mentioned could be the catalyst for a shutdown; many of which have no real middle-ground and/or politically tenable compromise," Kreuger wrote Monday. "Which is sort of why they have waited so long."
Experts estimate the US health care system wastes $765 billion annually — about a quarter of all the money that’s spent. Of that, an estimated $210 billion goes to unnecessary or needlessly expensive care.
In one instance, a hospital charged over $1,800 to pierce a 5-year-old's ears during surgery.
This is just one example of the ways waste is baked into the healthcare system in America.
This story was co-published with NPR’s Shots blog.
Two years ago, Margaret O’Neill brought her 5-year-old daughter to Children’s Hospital Colorado because the band of tissue that connected her tongue to the floor of her mouth was too tight. The condition, literally called being “tongue-tied,” made it hard for the girl to make “th” sounds.
It’s a common problem with a simple fix: an outpatient procedure to snip the tissue.
During a pre-operative visit, the surgeon offered to throw in a surprising perk. Should we pierce her ears while she’s under?
O’Neill’s first thought was that her daughter seemed a bit young to have her ears pierced. Her second: Why was a surgeon offering to do this? Wasn’t that something done free at the mall with the purchase of a starter set of earrings?
“That’s so funny,” O’Neill recalled saying. “I didn’t think you did ear piercings.”
The surgeon, Peggy Kelley, told her it could be a nice thing for a child, O’Neill said. All she had to do is bring earrings on the day of the operation. O’Neill agreed, assuming it would be free.
Her daughter emerged from surgery with her tongue newly freed and a pair of small gold stars in her ears.
Only months later did O’Neill discover her cost for this extracurricular work: $1,877.86 for “operating room services” related to the ear piercing — a fee her insurer was unwilling to pay.
At first, O’Neill assumed the bill was a mistake. Her daughter hadn’t needed her ears pierced, and O’Neill would never have agreed to it if she’d known the cost. She complained in phone calls and in writing.
The hospital wouldn’t budge. In fact, O’Neill said it dug in, telling her to pay up or it would send the bill to collections. The situation was “absurd,” she said.
“There are a lot of things we’d pay extra for a doctor to do,” she said. “This is not one of them.”
Kelley and the hospital declined to comment to ProPublica about the ear piercing.
Surgical ear piercings are rare, according to the Health Care Cost Institute, a nonprofit that maintains a database of commercial health insurance claims. The institute could only find a few dozen possible cases a year in its vast cache of billing data. But O’Neill’s case is a vivid example of health care waste known as overuse.
Into this category fall things like unnecessary tests, higher-than-needed levels of care or surgeries that have proven ineffective.
Wasteful use of medical care has “become so normalized that I don’t think people in the system see it,” said Dr. Vikas Saini, president of The Lown Institute, a Boston think tank focused on making health care more effective, affordable and just. “We need more serious studies of what these practices are.”
Experts estimate the U.S. health care system wastes $765 billion annually — about a quarter of all the money that’s spent. Of that, an estimated $210 billion goes to unnecessary or needlessly expensive care, according to a2012 report by the National Academy of Medicine.
We also reported howdrug companies make oversize eyedropsand vials of cancer drugs, forcing patients to pay for medication they are unable to use. In response, a group of U.S.senators introduced a billthis month to reduce what they called “colossal and completely preventable waste.”
But any discussion of waste needs to look how health care dollars are thrown away on procedures and care that patients don’t need — and how hard it is to stop it.
Just ask Christina Arenas.
Arenas, 34, has a history of noncancerous cysts in her breasts so last summer when her gynecologist found some lumps in her breast and sent her for an ultrasound to rule out cancer, she wasn’t worried.
But on the day of scan, the sonographer started the ultrasound, then stopped to consult a radiologist. They told her she needed a mammogram before the ultrasound could be done.
Arenas, an attorney who is married to a doctor, told them she didn’t want a mammogram. She didn’t want to be exposed to the radiation, or pay for the procedure. But sitting on the table in a hospital gown, she didn’t have much leverage to negotiate.
So, she agreed to a mammogram, followed by an ultrasound. The findings: no cancer. As Arenas suspected, she had cysts, fluid-filled sacs that are common in women her age.
The radiologist told her to come back in two weeks so they could drain the cysts with a needle, guided by yet another ultrasound. But when she returned she got two ultrasounds: one before the procedure and another as part of it.
The radiologist then sent the fluid from the cysts to pathology to test it for cancer. That test confirmed — again — that there wasn’t any cancer. Her insurance whittled the bills down to $2,361, most of which she had to pay herself because of her insurance plan.
Arenas didn’t like paying for something she didn’t think she needed and resented the loss of control. “It was just kind of, ‘Take it or leave it.’ The whole thing. You had no choice as to your own care.”
Arenas, sure she’d been given care she didn’t need, discussed it with one of her husband’s friends who is a gynecologist. She learned the process could have been more simple and affordable.
Arenas complained to The George Washington Medical Faculty Associates, the large Washington, D.C., doctor group that provided her treatment. Her request to have the bill reduced was denied. Then bill collectors got involved, so she demanded a refund and threatened legal action.
She said she never got to speak to anyone. Her demand was routed to an attorney, who declined her request because there was “no inappropriate care.” She also complained to her insurance company and the Washington, D.C., attorney general’s office, but they declined to help reduce the bill.
Overtreatment related to mammograms is a common problem. The national cost of false-positive tests and overdiagnosed breast cancer is estimated at $4 billion a year, according to a 2015 study in Health Affairs.
Some of this is fueled by anxious patients, some by doctors who know that missing a cancer diagnosis can be grounds for a medical malpractice lawsuit. But advocates, patients and even some doctors note the screenings can also be a cash cow for physicians and hospitals.
With Arenas’ permission, we shared her case with experts, including Dr. Barbara Levy, vice president of health policy for the American College of Obstetricians and Gynecologists and three radiologists.
Levy said there’s a standard way to treat a suspected breast cyst that’s efficient and cost-effective. If the lump is large, as in Arenas’ case, a doctor should first use a needle to try and drain it. If the fluid is clear and the lump goes away there’s no cause for concern or extra testing. If the fluid is bloody or can’t be drained, or the mass is solid, then medical imaging tests can determine if it’s cancerous.
However, doctors often choose to order imaging tests rather than drain apparent cysts, Levy said. “We’re so afraid the next one might be cancer even though the last 10 weren’t,” she said. “So, we overtest.”
Levy and the radiologists agreed that at least some of Arenas’ care seemed excessive. But their opinions varied, which shows why it can be difficult to reduce unnecessary care. Standards are often open-ended, so they allow for a wide range of practices and doctors have autonomy to take the route they think is best for patients.
The American College of Radiology recommends an ultrasound for a 32-year-old — Arenas’ age at the time of the procedure — with an unidentified breast mass. Mammograms are also an option, but “most benign lesions in young women are not visualized by mammography,” the guidelines state.
Dr. Phillip Shaffer, a radiologist who’s practiced for decades in Columbus, Ohio, said he didn’t think Arenas needed the mammogram. “I wouldn’t do it,” he said. “If I did an ultrasound and saw cysts, I’d say you have cysts. In 32-year-olds the mammogram does almost nothing.”
Dr. Jay Baker, chair of the American College of Radiology breast imaging communications committee, agreed that the ultrasound alone would have “almost certainly” identified the cyst. But, he said, maybe something about the lumps concerned Arenas’ radiologist, so a mammogram was ordered.
None of the radiologists consulted by ProPublica could explain why two ultrasounds on the return visit would be necessary. According to Arenas’ medical records, the practice told one reviewer that two were done to make sure the cysts hadn’t changed.
Shaffer didn’t buy it. “They just billed her twice for one thing,” he said.
Levy, the gynecologist, said it’s “excessive” to do two ultrasounds. And, she said, there was no need to send clear fluid to pathology.
Arenas offered to waive her privacy rights so the practice that provided her treatment could speak to ProPublica. Officials from the practice declined to comment. Her medical records show that in response to reviews by her insurance company and the attorney general’s office, her doctors said the care was appropriate.
Since then she has her cysts drained without images in her gynecologist’s office for about $350. But Arenas said on two occasions she’s used a needle at home to do it herself. (Doctors do not recommend this approach.) She admits it was an extreme choice, but at the time she worried she would be subjected to more unnecessary tests.
“I was taken advantage of because I was a captive audience,” she said.
In a brick-and-glass office park just outside Roanoke, Virginia, Missy Conley and Jeanne Woodward have battled on behalf of hundreds of patients who believe they’ve been overtreated or overcharged. The two work forMedliminal, a company that challenges erroneous and inflated medical bills on behalf of consumers in exchange for a share of the savings.
The two women excitedly one-up each other with their favorite outrages. How about the two cases involving unnecessary pregnancy tests? One of the patients was 82 —decades past her childbearing years. The other involved a younger woman who no longer had a uterus.
Another case involved an uninsured man who fell off his mountain bike and hurt his shoulder. The first responders pressured him to take an air ambulance to a hospital when it would have been faster for his friends to drive him. He got charged $44,000 for the whirlybird. Such unexpectedly pricey flights — and the aggressive billing that comes with them — have been featured in stories byNPR,The New York TimesandThe Atlantic.
Medliminal gets dozens of calls a week from consumers who are fed up with the medical system.
Woodward, a nurse and certified medical auditor, regularly sees patients billed for unnecessary lab tests. A man with diabetes may only need his glucose measured, but the doctor may order a bundle of 14 unnecessary tests, she said. The extra tests inflate the tab.
If there’s a billing dispute it can take months of phone calls and emails to get a case resolved, said Conley, who gained an insider’s knowledge during years working for insurance companies.
Patients fighting bills on their own often give up and pay the bill or let it go to collections, she said. “The whole system is broken,” Conley said.
Saini, president of The Lown Institute, said profit is a major driver of overuse.
“Providers are getting constant messages from superiors or partners to maximize revenue,” Saini said. “In this system we have, that’s not a crime. That’s business as usual.”
Patients aren’t true health care consumers because they typically can’t shop by price and they often don’t have control over the care they receive, Saini said. The medical evidence may support multiple paths for providing care, but patients are unable to tell what is or is not discretionary, he said. Time pressure adds urgency, which makes it difficult to discuss or research various options.
“It’s sort of this perfect storm where no one is really evil but the net effect is predatory,” Saini said.
Once the service or treatment is provided, the bill is on its way, with little forgiveness.
In 2015, Dr. Dong Chang, the director of the medical intensive care unit at Harbor-UCLA Medical Center, a public hospital in Los Angeles, decided to see whether the care being delivered in his ICU was appropriate.
Resources were scarce in his ICU, and he suspected it might be possible to manage them better. So, he and his colleagues reviewed the records of all the patients in the unit over the course of a year to see whether the patients might have been either too sick, or too healthy, to benefit from intensive care.
The results shocked them. They determined the care may not have been beneficial to more than half of the patients. “ICU care is inefficient, devoting substantial resources to patients less likely to benefit,” their study, published in theFebruary edition of JAMA Internal Medicine, concluded.
Chang and his team also reviewed the use ofintensive care at 94 hospitalsin two states, Maryland and Washington, focusing on four common conditions that can lead to treatment in an intensive care unit.
They found wide variation in the types of patients hospitals determined needed intensive care. One hospital put 16 percent of patients withdiabetic ketoacidosis, a serious condition that can result in a coma, in intensive care, while another hospital did so with 81 percent of such patients. The range for patients withpulmonary embolismswas from 5 percent to 44 percent and for those with congestive heart failure, it was 4 percent to 49 percent.
Chang attributes the difference to doctors using intensive care based on their habits, hunches or training. Profit, he said, may also be a motive, but it didn’t appear to be a driving force.
“We really don’t have good standards and a good discussion going on about who should receive ICU care,” Chang said.
The unnecessary intensive care can also be harmful. The study found intensive care patients underwent more invasive procedures, like the insertion of catheters, includingcentral lines, which carry the risk of infection. Overuse of the ICU is bad for patients who don’t need it, Chang said. Survival rates were also no better at the hospitals that used intensive care the most.
Reducing unneeded intensive care stays would save big money. Intensive care costs about $10,000 for a typical stay and accounts for 4 percent of national health care expenditures, according to research cited by Chang’s team.
If the hospitals in Maryland and Washington with the highest rates of intensive care use had behaved more like those with lower use, it would save around $137 million, the study estimated. That’s the savings for fewer than 100 hospitals in two states. There are about 4,000 hospitals nationwide, suggesting that reducing unnecessary intensive care use could save billions of dollars a year.
Chang hesitated to call the overuse of intensive care “wasted” health care spending. He said the medical literature calls it “non-beneficial” care, which is maybe a nicer way of saying the same thing.
For O’Neill, her dispute of the fee for her daughter’s ear piercing was a trip into the hell of medical billing.
O’Neill is an attorney, so she knows how to weed through fine print. But it took her untold hours and phone calls to the hospital and her insurance company to root out the issue. The hospital had initially billed her insurer for the $1,877.86 for “operating room services” related to the ear piercing. The company rightly rejected payment for the cosmetic procedure. So, the hospital billed the family, according to her medical and billing records and correspondence.
The surgeon billed the family an additional $110, which O’Neill paid.
The operative report describes the piercing in obscure technical terms: “The bilateral lobules were prepped with betadine and a 18 gauge was used to pierce the left lobule in the planned position …”
O’Neill said she got nowhere in several conversations with the manager of the hospital’s team that deals with payments directly from consumers. Then in mid-July, O’Neill wrote a letter to the manager explaining that they were at an impasse and urged the hospital to cancel the bill.
Republican leaders in the House and Senate released plans to extend government funding by two weeks, to December 22, to avoid a government shutdown.
This will give the GOP and Democrats time to hash out a deal on a funding bill that is expected to include a variety of other issues.
Congressional leaders will meet with President Donald Trump at the White House on Thursday.
Republicans in Congress are planning to delay a government shutdown for two weeks with a short-term funding bill, setting up an intense December of negotiations.
Senate Majority Mitch McConnell released a statement Monday saying that he planned to introduce a clean funding extension to push back the start of a shutdown to December 22. The current funding bill runs out at the end of the day Friday.
"This bill – one without any controversial policy riders – will continue government funding and give the House and Senate time to complete their work on a long-term solution," McConnell said in the statement.
"It will keep the government open and functional, and it includes critical resources for our national defense and to give states certainty to continue the Children’s Health Insurance Program while the bipartisan work on CHIP reauthorization continues."
The bill will give Republicans and Democrats time to debate a larger funding package.
Democrats want to include a slew of legislative priorities in the funding bill, including codifying the Deferred Action for Childhood Arrivals (DACA) program, an Obamacare stabilization package, and long-term funding for the Children's Health Insurance Program.
Republicans want to secure funding for President Donald Trump's promised border wall and increase the defense spending caps.
The House rolled out its text for a two-week funding bill on Monday.
Congressional leaders from both sides of the aisle will meet with Trump on Thursday to hash out funding issues. Democratic leaders Chuck Schumer and Nancy Pelosi pulled out of the first such meeting Tuesday due to a tweet from Trump attacking them and suggesting no deal was possible.
Enrollment on the federally run Affordable Care Act exchanges is outpacing 2016.
But it's projected to fall short overall because of a shorter time window for people to enroll.
Other actions from the Trump administration will likely lead to fewer Americans signing up for coverage.
Experts say this will likely lead to higher insurance premiums.
Sign-ups for next year on the federally run Affordable Care Act insurance markets are crushing their pace from last year. But darker clouds loom on the horizon.
According to the Centers for Medicare and Medicaid Services (CMS), about 3.6 million plans have been selected on the federally run Healthcare.gov exchanges through December 2 — about 2.6 million people renewing coverage and just under 1 million new customers.
That's the positive news for the healthcare law. The not-so-good news: The open enrollment period for 2017 is significantly shorter this year compared to last. The Trump administration shrunk the sign-up stretch to six weeks instead of three months.
With the December 15 deadline fast approaching, the number of plan selections is well short of the more than 9 million people who signed up on the federal exchange last year.
Larry Levitt, senior vice president at the Kaiser Family Foundation, a nonpartisan healthcare policy organization, said there will likely be a significant kick of sign-ups near the finish — since auto-enrollments will be added onto the final numbers. But it will likely not make up for the shortfall.
"It seems pretty clear at this point that the combination of a shorter sign-up period and massive reductions in outreach will lead to lower enrollment and more people uninsured," Levitt told Business Insider.
Obamacare markets could see big problems
Levitt hinted at another reason experts say there has been a drop in enrollments. The Trump administration cut its advertising budget by around 90%. Money to in-person navigators, who help people find plans, dropped by just over 40%.
Matthew Fiedler, a fellow at the Brookings Institution's Center for Health Policy, said there are a lot of reasons for the enrollment drop-off — but not one that stands out above others.
"My view is that various administration actions — including the shorter enrollment period, the reduction in outreach funding, higher premiums for unsubsidized consumers due to policy uncertainty, and consumer confusion about the ACA’s future — have weighed on enrollment, but the size of each of those effects is uncertain," Fiedler told Business Insider.
Fiedler said that the decrease in enrollment will likely be detrimental to people enrolled on the exchanges.
"In terms of what the effects of lower enrollment will be, a lower uninsured population will be damaging. The additional uninsured will have worse access to care and be less financially secure," Fiedler told Business Insider. "Similarly, other individual market enrollees will face higher premiums since the lost enrollees are likely healthier than average, and health care providers will face higher uncompensated care costs."
Levitt, on the other hand, argued that there are "countervailing forces" in the market due to the shorter enrollment period.
"A shorter period means less chance that someone who wasn’t planning to sign up gets sick and then enrolls," Levitt said. "That may only be a handful of people, but they could have very expensive health conditions."
Given this factor, he said, the actual effect on premiums is "unclear."
Fiedler said that the Obamacare markets could still "muddle through" even with lower enrollment.
"While bad, enrollment declines are not an existential threat to the individual market," he said. "The impact of enrollment declines on the risk pool are smaller than sometimes thought. Furthermore, the rate increases insurers implemented for 2018 appear to be large enough to accommodate the deterioration in the risk pool we are likely to see."
Oscar Health, the $2.7 billion health insurance startup, wants to have all of its members using concierge medical care in 2018.
The plan to create 'Concierge for All' relies on teams of doctors and other healthcare professionals who work with Oscar to help you navigate everything from insurance benefits to questions about your health.
It's something people often spend tens of thousands of dollars on every year in addition to their traditional insurance.
Oscar Health, the health insurance startup, is giving all of its members access to a team of healthcare professionals they can turn to for help navigating their healthcare.
The service is what's known as concierge care, and it might seem like a foreign concept to most Americans who struggle navigating the often complex and frustrating healthcare market. But such personalized care often comes at a high cost. Some 'boutique' or high-end concierge services can cost as much as $40,000 a year per family, on top of the insurance premiums that family pays.
Oscar is trying to change that. The $2.7 billion health-insurance startup is making a big push to make concierge care the centerpiece of their members' healthcare experience, with all its members using it.
Here's how it works
Oscar members are assigned a personalized concierge team of one nurse and three clinicians with specialized knowledge of the patient's local healthcare networks. The idea is that teams with localized knowledge will be better informed when making recommendations and referrals.
Those healthcare professionals can answer any questions you have about your insurance benefits, or about that strange bump on your neck, help the member get a prescription or a referral to a specialist.
While Oscar members don't physically meet with their teams, they can contact them over the phone or through secure messaging on the company's mobile app.
Concierge doctors will also be able to initiate contact with their patients with the help of clinical dashboards, which collect claims records and other data about the patients' medical history to give doctors more context on a person's health than what they might otherwise learn from electronic health records.
"One of the things that we are able to do because we have a lot of data is to flag to care teams the defective conditions that members may have in our clinical dashboard and say 'hey, you really should go in and see a doctor. We think you might have something and you should get some medication for it,'" Chelsea Cooper, Oscar's Senior Vice President of Member & Strategy Operations, told Business Insider. "And that’s something we’re able to do because we’re a tech company."
Since launching its concierge services in full earlier this year, Oscar says 70% of its roughly 90,000 members have interacted with a concierge team, although those who engaged had an average of only three interactions. The company says concierge care has even helped its members save money on out-of-network costs.
Now Oscar is trying to universalize the service with a "Concierge for All" campaign to encourage 100% of its members to start using it next year.
"We think healthcare is very personal and that these changes really matter," Cooper said. "You want to know the [concierge team] so that you can trust them and take their recommendations about which doctor to go to and whether you should go to the ER or an urgent care facility. We try to build that connection."
Surviving as the market shifts
The future of American healthcare has taken on new dimensions over the last year as President Donald Trump and Republicans in Congress attempt to repeal Obamacare. But Oscar keeps pushing forward.
Earlier this year, Oscar announced it would start offering health insurance plans alongside the Cleveland Clinic in Ohio for the first time. In 2018, it plans to expand coverage from three states to six.
Despite its optimism, Oscar is not immune to the financial challenges of the turbulent healthcare market.
Last month, Oscar reported a $96 million third quarter loss across the three states where it currently sells coverage, according to Forbes. Although it was an improvement from the same quarter in 2016, it was in line with a continuing losses the company has experienced since its founding in 2012.
But Oscar's chief technology officer Alan Warren told Business Insider in June that such challenges, including the political debate over healthcare in Washington, will ultimately do little to deter the company from carrying out its mission. When the Trump administration slashed Obamacare advertising funding by 90% earlier this year, for example, Oscar ratcheted up its own advertising campaign in New York just in time for the most recent open enrollment period, which ends on Friday.
The House on Tuesday passed the Republican tax bill in a 227-203 vote.
If passed into law, the bill would make significant changes to the Affordable Care Act.
President Donald Trump could sign the bill as soon as Wednesday.
The GOP is on the brink of passing its massive tax reform bill.
On Tuesday, the House and Senate voted in favor of the bill. If a last-minute technical vote passes — after the House revotes on the bill on Wednesday— President Donald Trump could sign the bill as soon as Wednesday.
The bill would repeal the individual mandate, the provision in the ACA that requires individuals to have health insurance or face a penalty fee.
Without the individual mandate, healthy people may opt out of getting insurance, and the number of uninsured Americans would increase by 13 million by 2027, according to the Congressional Budget Office. Premiums on the individual market are expected to increase about 10% a year over the next decade without the mandate.
The CBO also said that the insurance markets in "almost all areas" of the country would remain stable.
The repeal of the individual mandate would also have a small effect on the employer market as well, with 3 million fewer people opting into employer coverage.
Republican Sen. Susan Collins of Maine had voted against all versions of the ACA repeal bill over the summer, but ultimately is expected to vote in favor of the tax bill. Collins, who was concerned the individual mandate repeal would increase premiums, said she got Senate Majority Leader Mitch McConnell to support two pieces of legislation that would stabilize the ACA.
"While this legislation is by no means perfect, on balance, it will provide much-needed tax relief," Collins said in a statement Monday.
President Donald Trump applauded the near-passage of the GOP tax bill on Wednesday during a Cabinet meeting at the White House.
Trump said the bill's repeal of the Obamacare individual mandate "means Obamacare is being repealed."
This is not true. Many of Obamacare's elements remain intact.
President Donald Trump applauded the near passage of the GOP tax bill Wednesday during a Cabinet meeting in which he made a false claim about its affect on the Affordable Care Act.
"The individual mandate is being repealed, that means Obamacare is being repealed because they get their money from the individual mandate," Trump said.
The mandate, which requires most Americans to get health insurance or pay a fine, is repealed in the GOP tax bill. But that does not mean the entire law is being repealed.
The expansion of Medicaid under the ACA, which helped cover an additional 15 million people, remains in place in the states that have opted to expand the program.
Other policy changes from the law, such as insurance companies' inability to reject a patient due to a preexisting condition and mandatory coverage of basic health needs like prescriptions, remain in place.
In fact, according to the Congressional Budget Office, the Obamacare individual insurance markets are likely to remain relatively stable — albeit with a lower enrollment total — even without the mandate.
But the mandate repeal could still bring about adverse affects on the healthcare market.
The CBO estimated that 13 million more people would go without insurance by 2027 without the mandate than if it remained in place. It also estimated that premiums in Obamacare markets would jump 10% over the current baseline.
Most consumers will be shielded from the increase due to subsidies from the federal government, but as many as 2 million Americans could be priced out of insurance, according to the CBO.
Watch Trump's remarks here:
President Trump on repeal of Obamacare's individual mandate: "So, in this bill not only do we have massive tax cuts and tax reform, we have essentially repealed Obamacare and we'll come up with something that will be much better."https://t.co/5A4GmFds8Bpic.twitter.com/0WBwwCU1J1
Republican Sens. Lamar Alexander and Susan Collins are delaying their effort to pass two bills aimed at stabilizing Affordable Care Act insurance markets.
The senators are aiming to pass the bills as part of an omnibus spending bill in January instead.
Collins predicated her support for the GOP tax bill in part on a promise of GOP support for these measures.
Republican Sens. Lamar Alexander and Susan Collins are delaying their effort to pass two bills aimed at stabilizing Obamacare insurance markets, they announced on Wednesday.
The senators originally promised to include the measures in a year-end spending bill, but because Congress is only working to pass a short-term extension of federal government funding this week, Collins and Alexander say they will include the bills in an omnibus bill in January.
"It looks like the Christmas present of lower health insurance premiums will now have to be a Valentine's Day present,"Alexander said in a statement. "It is hard to add our bills to a year-end package that does not yet exist."
Collins, who predicated her support for the GOP tax bill in part on a promise of GOP support for these bipartisan measures, said on Wednesday that Republican leadership has assured her that the party will vote for the bills in the new year. The GOP tax bill, which the president is set to sign on Wednesday, eliminates the Affordable Care Act's individual mandate, which will grow the ranks of uninsured Americans by 13 million.
"This afternoon Speaker Paul Ryan called me and said that the House remains committed to passing legislation to provide for high-risk pools and other reinsurance mechanisms similar to the bipartisan legislation I have introduced,"Collins wrote in statement.
Collins, a moderate who voted against the GOP's efforts to repeal and replace Obamacare earlier this year, says the bills will offset the impact of the loss of the individual mandate, but experts largely disagree, arguing that the elimination of the mandate will spike health costs and reduce choice in plans.
Their moves comes after Collins told reporters on Tuesday that she had confirmed with Senate Majority Leader Mitch McConnell that he would support the two insurance bills as well as a measure waiving an automatic cut in Medicare that the tax bill could trigger.
Collins and Alexander have lobbied President Donald Trump for months to support provisions that would help stabilize the volatile Obamacare insurance markets. But most Republican lawmakers have remained adamantly opposed to the proposals, which they see as propping up the law.
Nevertheless, the senators say they remain confident that bipartisan versions of the proposals will pass in the new year.
"There is every reason to believe that these important provisions can and will be delivered as part of a bipartisan agreement," the statement read. "And Majority Leader McConnell has told us that he will uphold his commitment to schedule and support the legislation."
About 8.8 million people enrolled in Obamacare plans for 2018 through the federal Healthcare.gov marketplace.
That was only slightly less than the 9.2 million people that enrolled last year, despite attempts to undermine the law by the Trump administration.
The number does not include the 12 state-run exchanges, many of which have longer sign-up periods.
Even without its namesake in office, the law known as Obamacare barely slowed down in 2017.
Seema Verma, the administrator of the Centers for Medicaid and Medicare, said Thursday that 8.8 million people enrolled in insurance plans for 2018 through the federal Healthcare.gov exchange.
That falls just 400,000 short of the 9.2 million that enrolled in 2017 plans, meaning the current sign-up period drew just under 96% of last year's enrollment.
The number was particularly surprising given the Trump administration's attempts to meddle in the sign-up period. It dramatically slashed the budget for outreach and advertising and cut the enrollment window to just six weeks rather than three months.
There was a significant surge in the last few days of enrollment. As of December 9, just a few days before the December 15 deadline, 4.6 million were people enrolled. CMS said more than 4.1 million people, including those who automatically enrolled, signed up in the final week.
According to the report, 6.4 million enrollees were returning customers renewing coverage, up from 6.2 million last year. New enrollees dropped to around 2.4 million from 3 million last year.
The total does not include state-run marketplaces, many of which still have ongoing sign-up periods.
Health policy experts were taken aback by the numbers, as the total of enrollees exceeded initial expectations. Larry Levitt, senior vice president at the Kaiser Family Foundation, a health policy think thank, called the number "truly remarkable."
"I confess to being very surprised that ACA marketplace enrollment is down only slightly," Levitt tweeted. "That didn't seem possible with a 90% reduction in outreach, an enrollment period cut in half, and a constant refrain that the program is dead."
The final tally for the federal exchange comes the day after Republicans passed their tax bill which repeals Obamacare's individual mandate, a key piece of the law.
"The individual mandate is being repealed, that means Obamacare is being repealed because they get their money from the individual mandate," the president said Wednesday.
While the Congressional Budget Office estimated that 13 million more people would be without insurance in 2027 without the mandate compared to with it, the office also said that the Obamacare exchanges would remain stable under the law and many people would be shielded from possible premium increases due to government subsidies.
A two-week period in July was one of the most pivotal times in Donald Trump's young presidency.
It laid bare the splintering of Trump's relationships with influential Cabinet members, foreshadowed the reach of the Russia probe, saw the defeat of a signature campaign promise, and featured a major staff shakeup.
These events encapsulated both the promise and peril of Trump's first year in office.
WASHINGTON (AP) — They were the 13 days that transformed the White House.
Even for an administration that spent most of 2017 throwing off headlines at a dizzying pace, events in the second half of July unfolded at breakneck speed. They encapsulated both the promise and peril of President Donald Trump’s first year in office — and yielded aftershocks that reverberate within the White House even as the calendar turns to 2018.
The two-week span laid bare the splintering of Trump’s relationships with two influential Cabinet members, foreshadowed the reach of the Russia probe into the interior of his orbit; saw the dramatic, last-minute defeat of one of the president’s signature campaign promises; and featured a senior staff shakeup that reset the rhythms of this presidency.
From the outside, it was an unruly stretch that threatened to turn the White House into a sideshow.
Inside the West Wing, the chaotic days between July 19-31 stand as a panicked memory but also one that also paved the way for future successes, according to nearly two dozen administration officials, outside advisers and lawmakers.
Most of those interviewed for this account spoke anonymously because they were not authorized to talk publicly about private discussions.
For the record, though: “That was the extreme,” said former press secretary Sean Spicer.
The kiss
His suit perfect and his hair just so, Anthony Scaramucci lifted his right hand off the briefing room podium and blew a kiss to the slack-jawed White House press corps.
Trump’s new communications director, known to his friends as the Mooch, made his dramatic debut on July 21 and aimed to usher in a new era at a White House riven by in-fighting, drowning in bad press and struggling to maintain credibility.
He lasted 11 days.
Scaramucci’s shockingly brief tenure — some White House aides have taken to calling a short period of time a “Mooch” — underscored the drama that dominated and frequently paralyzed the West Wing.
This was a White House where aides undermined each other with blind items in the press and jockeyed for face time with a president who left the Oval Office door open. Self-proclaimed “nationalists,” led by chief strategist Steve Bannon, were pitted against more centrist “globalists,” who included Trump’s powerful adviser and son-in-law Jared Kushner.
How the rivalries played out in the press was particularly important for Trump, the former reality TV star who consumes hours of cable news each day. For months, he demanded that his schedule be arranged so he could watch the daily White House press briefing, often barking at aides about what he was seeing in between sips of Diet Coke in his private dining room.
Some of his rants were about the “fake” news media. But many were about Spicer, whom Trump believed failed to adequately defend him — or to look the part. Long believing he was his own best spokesman, Trump told one confidant that he saw something of himself in Scaramucci, a rich, fast-talking New York hedge fund manager who excelled on television.
Within hours of when Scaramucci was hired, Spicer quit.
That was only the beginning of the drama: Scaramucci fired one staffer and threatened to push others out, including the entire press shop. He vowed to cut down on leaks, but many in the White House believed that was a cover story for his own vengeful agenda.
Believing that Bannon and White House chief of staff Reince Priebus had initially blocked his entrance to the White House, Scaramucci moved to oust them, culminating in a New Yorker interview in which he graphically cursed out both men.
Scaramucci himself was pushed out the door days later. Scaramucci’s expletive-laden interview was only part of the problem.
Trump was unwilling to share the spotlight with an aide, and came to believe Scaramucci had forgotten his place.
The tank
Tension was thick in the air as Trump and several top advisers strode out of a windowless room at the Pentagon on July 20 and climbed into a waiting motorcade.
Over the previous 150 minutes, top U.S. officials had explained to the president the critical importance of forward worldwide deployments of U.S. military, intelligence and diplomatic assets.
For months, Trump had questioned why the U.S. government needed “so many people” abroad and suggested that he wanted to reduce its footprint, an idea that triggered alarm in capitals around the globe.
Armed with charts, maps and diagrams, Defense Secretary James Mattis, Secretary of State Rex Tillerson and others schooled Trump with talking points and commentary sure to click with the former businessman.
They stressed the role that the military, intelligence officers and diplomats play in making the world safe for American businesses like The Trump Organization to operate and expand abroad. In a limited way, Trump agreed with Mattis and Tillerson, grudgingly agreeing to increase the number of U.S. forces in Afghanistan.
But on a broad range of foreign policy matters, Trump has steadfastly refused to adopt conventional approaches, straining decades-long alliances, refusing to condemn authoritarian regimes on human rights abuses and escalating the rhetoric in a nuclear stand-off with North Korea.
The meeting in Room 2E924, known as “The Tank,” highlighted the sharp learning curve that the president, who had never held elected office or served in the military, faced as he grew into his new job.
It also revealed the tensions within the administration between those from Washington’s national security establishment and those eager to pull back from international entanglements.
That rift only grew after the top-secret gathering. It was soon after the meeting concluded that Tillerson was reported to have privately called the president “a moron.”
The secretary of state pointedly did not deny that he had done so — eventually, a State Department spokeswoman did — and it prompted a furious response from Trump, who repeatedly undermined Tillerson on his approach to North Korea.
But Tillerson was not the only attendee at The Tank to have misgivings after the session.
In the days that followed, Joseph Dunford, chairman of the Joint Chiefs of Staff, encouraged his best friend, Homeland Security chief John Kelly, to take the White House chief of staff job.
The general
Buffeted by fierce rains and wind, Air Force One circled over Washington on July 28. When it finally touched down at Joint Base Andrews, a new phase of the presidency began.
In a series of tweets, Trump announced that he was appointing Kelly, a retired four-star general, to replace Priebus. As the 140-character bursts reached their smart phones, a pair of senior White House aides who been sitting in an idling SUV with Priebus stepped out onto the rainy tarmac and left the outgoing chief of staff alone.
Priebus never could bring a semblance of order to the rivals that populated Trump’s West Wing and the president had openly mused about replacing him. Never empowered to fully step into the role, Priebus often acted as merely the captain of his own squad of establishment Republicans, vying with Bannon and Kushner for influence.
Trump had previously floated the job to Kelly, who initially demurred. Kelly told confidants he had a change of heart because he felt that the president’s term had been imperiled by poor staff work.
“I don’t think you can overestimate the effect of the impact of those (staff) changes and that period,” Marc Lotter, Vice President Mike Pence’s spokesman, said at the time.
One of Kelly’s first official moves was to fire Scaramucci. In the months that followed, other headline-grabbing aides — Bannon, Sebastian Gorka and Omarosa Manigault-Newman — also were pushed out as Kelly tried to enforce a one-team ethos. Most impactfully, aides said, Kelly worked to cut down access to the Oval Office and seize control of how information reached Trump.
Several advisers deemed Kelly’s hire a turning point for the administration, a move that cut down on internal fights, restored order to the West Wing and laid the groundwork for wins down the road.
“Once myself, Reince and Steve were out of the picture, I think that moved the target off — it got people back to focus,” Spicer recalled.
But there were limits to what Kelly could — or would — control.
The chief of staff made clear he would mount no effort to manage Trump’s no-holds Twitter habit. And Trump, in turn, chafed at Kelly’s handling.
The thumbs-down
Majority Leader Mitch McConnell stood on the Senate floor, his arms crossed, his face impassive. Trump, back at the White House, had hung up the phone, his last attempt at persuasion over.
At 1:29 a.m. on July 28, Republican Sen. John McCain of Arizona strode onto the Senate floor. The 80-year-old, just weeks after a brain cancer diagnosis, was poised to cast the tiebreaking vote on the GOP’s health care bill, in what was meant to be the fulfillment of seven years of work to undo President Barack Obama’s signature health care law.
McCain paused for a moment, and then flashed a thumbs-down, drawing gasps from fellow senators. The bill was dead, and the White House had been dealt a devastating blow.
Though Trump had spent the presidential campaign promising to repeal and replace Obamacare on Day One of his administration, the Republican effort had failed. It was a fiasco that underscored how the White House was struggling to push through Trump’s agenda even though his party controlled both houses of Congress.
Frequently exhibiting a shaky grasp of policy details, Trump often baffled aides by waffling on various options — including whether the GOP should repeal the Affordable Care Act and come up with a replacement later, or let it simply starve by not paying subsidies. His approach to lawmakers on Capitol Hill was equally inconsistent.
Trump snarled in private about McConnell and House Speaker Paul Ryan and showed no hesitation to air his grievances publicly. He used Twitter to deliver broadsides against the majority leader — urging him to “get back to work” — and targeted individual Republican senators whose health care votes the White House once courted.
But from the ashes of the health care defeat came the administration’s first major legislative triumph: the tax cut legislation passed on Dec. 20.
The bungled legislative process on health care sparked a new call for discipline in the administration’s approach to Capitol Hill. The White House would buy in to the plan at the start. Staff would cajole wavering legislators and work to resolve their concerns while there was still time to address them. Trump’s political operation would begin work to sell the tax package in the approaching midterm elections.
Trump himself worked behind the scenes making phone calls to key members and, perhaps more importantly, reined in his public criticism of members of his own party. With just 11 days left in 2017, Republicans from the House and Senate stood on the White House South Lawn and applauded as the president announced the bill would become law.
Trump allowed that he’d learned a thing or two — about the importance of relationships, in particular.
“When I came, I didn’t know too many,” he said Friday of the legislators. “I can call anybody now. I know every one of them very well.”
The Raid
The sun had not yet risen on July 26 when FBI agents arrived without warning at the front door of Paul Manafort’s home in Alexandria, Va.
Using a search warrant, they emerged from the home of Trump’s former campaign chairman with a trove of material. A new, more dangerous, chapter had begun in special counsel Robert Mueller’s investigation into possible coordination between the president’s campaign and Russian officials.
The raid was a stark reminder for the White House that, no matter the successes or failures of the moment, the cloud of the Russia probe loomed on the horizon. Trump had grown furious at the distraction, fuming to advisers that he had done nothing wrong while railing that it was a conspiracy by Democrats and the so-called “deep state” to delegitimize his presidency.
Exactly one week before the raid, Trump sat in the Oval Office with reporters from The New York Times and, with little prompting, veered into an attack on his own attorney general, Jeff Sessions. Trump blasted Sessions, once one of his closest allies, for recusing himself from the Russia probe, believing that helped lead to Mueller’s appointment.
Trump continued his assault in a series of tweets in which he called Sessions “weak” and “beleaguered.” Privately, he discussed firing Sessions, but was met with a wave of resistance from his advisers. Some warned it would worsen the Russia probe, while Bannon told the president it would hurt with his base supporters, who loved Sessions’ tough-on-crime approach at the Justice Department.
Kelly, in his first weekend on the job, called Sessions to assure him his position was safe. But the rift between Trump and Sessions still has not healed. Recently, Trump bemoaned the Republicans’ loss in a special election in Alabama and in part blamed Sessions, whose departure from the Senate to head to Justice necessitated the election.
And the Mueller investigation shows no signs of ending.
Scores of top aides and allies, including Kushner and Trump’s eldest son, Donald Jr., have been questioned by Mueller and congressional investigators. In October, Manafort was charged with money laundering and other financial crimes related to his political consulting work in Ukraine. Several other Trump associates also have been charged by Mueller, including former national security adviser Michael Flynn, who pleaded guilty to lying to FBI agents and is cooperating with the investigation.
Though still shadowed by the probe, Trump emerged from the crucible of the 13 days in July with a more organized and less drama-filled White House, as well as lessons learned that would yield legislative victories.
But the president himself remains unchanged.
Impulsive and unconventional, Trump has spent his first year in office casting aside norms and mores. With his Twitter account as his weapon, the president has shown no willingness to ignore any slight or change the brash ways that he believes got him elected.
“I said with the exception of the late great Abraham Lincoln, I can be more presidential than any president that’s ever held this office,” Trump told a rally crowd in Ohio on July 25. “It’s so easy to act presidential, but that’s not gonna get it done.”
2018 kicks off with a busy month for Congress, which has until January 19 to pass a bill to fund the government.
Democrats and Republicans want the bill to address issues like healthcare, immigration, and government surveillance.
Republicans and President Donald Trump are also eyeing other legislative plans for the year.
President Donald Trump and congressional leaders are about to face a slew of deadlines that could result in a shutdown early in the new year.
Congress must pass legislation to fund the government by January 19 to avoid a partial government shutdown. Negotiations look set to be fraught, as Republicans and Democrats alike will attempt to resolve a series of legislative issues by attaching other agenda items to the must-pass bill.
Not only does Congress have to deal with the mandatory deadlines, but GOP leadership is also likely to set its sights on the next big legislative push after completing its massive tax-code overhaul. What that will be remains up in the air.
The 'need to pass' legislation
After lawmakers repeatedly punted on substantial fiscal deadlines in 2017, the route to avoiding a shutdown appears much more complicated this time around.
Here's a rundown of just some of the issues that members of Congress want to include as part of the funding negotiations:
Deferred Actions for Childhood Arrivals program: The Obama-era immigration program, which protects more than 700,000 unauthorized immigrants who arrived in the US as minors, is set to expire in March after Trump gave Congress a six-month deadline to codify the program. Democrats have made the program a top priority in the funding negotiations.
Obamacare stabilization: Republican leaders assured GOP Sen. Susan Collins amid tax-bill negotiations that they would hold a vote on the bipartisan Alexander-Murray bill, which was designed to stabilize the Affordable Care Act's individual insurance markets. The vote was delayed until 2018, however.
Children's Health Insurance Program: Congress authorized $3 billion more for CHIP before the holiday to prevent children from losing health coverage. But it still has not come to a long-term solution to maintain the program. Democrats want a simple extension of funding for it, while the GOP wants to pair the extension with cuts to healthcare spending elsewhere.
Government surveillance powers: Section 702 of the Foreign Intelligence Surveillance Act, which authorized the National Security Agency and others to collect large amounts of data and communications, is set to expire January 19. Many Democrats and Republicans alike want to curtail the surveillance powers, and adjustments to the program could be included in the funding bill.
Disaster relief: The White House and lawmakers from areas affected by hurricanes and other natural disasters in 2017 have asked for billions more in aid to rebuild those areas.
Congress punted twice on dealing with government funding before the holiday break, extending it only for weeks at a time as Republicans rushed to pass their tax bill. With the tax bill passed, the probability of a shutdown this time around is higher, said Isaac Boltansky and Lukas Davaz, analysts at the research firm Compass Point.
"Our sense is that the successful enactment of tax reform has left neither party eager to compromise on other issues," Boltansky and Davaz wrote in a note to clients. "We peg the odds of a government shutdown in mid-January at 60% given the current state of play in DC."
Republican leaders have floated several options. For instance, House Speaker Paul Ryan immediately began to set his sights on cuts to entitlement programs like Medicaid and Medicare. Senate Majority Leader Mitch McConnell has said Republicans' slim 51-49 majority in the Senate most likely means that won't be an option.
"We are bearish on efforts to curtail entitlement spending in this Congress given the lack of Democratic support for the effort in the Senate, tentativeness among certain Republicans, and a basic lack of procedural bandwidth before the midterms," the Compass Point analysts said.
After the tax bill passed, many Trump officials began to talk up the possibility of moving forward on the package. Among them were Marc Short, the White House director of legislative affairs, and Gary Cohn, the National Economic Council director.
McConnell has said an infrastructure push is on the table but will most likely need Democratic support.
Chris Krueger, an analyst at Cowen Washington Research Group, said a large package could be difficult since the parties have a slew of policy differences on infrastructure — such as how to pay for it.
"Infrastructure is very hard to shoe-horn into a reconciliation bill, so Democratic Senate votes will be needed (at least nine)," Kreuger said in a note. "The House Freedom Caucus is lukewarm on public works spending, so there is a real arithmetic problem."
Trump, McConnell, and Ryan are set to meet at Camp David over the weekend to hash out the strategy for year two of the Trump presidency — both in the immediate fights over funding and in the longer-term push.
The Department of Labor unveiled its proposed rule that would pave the way for association health plans.
These plans would allow self-employed individuals and small businesses to join to get health insurance plans, instead of obtaining the insurance through the Affordable Care Act marketplace.
The introduction of association health plans could make the Obamacare marketplace more unstable.
The Trump administration has taken another step to dismantle one of the key parts of the Affordable Care Act.
The Department of Labor on Thursday unveiled its proposed rule for association health plans, a move put in motion by the executive order President Donald Trump signed in October.
Association health plans are set up to allow people who get their insurance through the Obamacare's individual or small-group insurance plans to join together to buy insurance at a better rate. Under the Department of Labor's proposal, the plans would also not be subject to certain Obamacare regulations, which could help make them cheaper.
"The goal of the rulemaking is to expand access to affordable health coverage, especially among small employers and self-employed individuals, by removing undue restrictions on the establishment and maintenance of association health plans under ERISA," or the Employee Retirement Income Security Act, the department wrote in the proposed rule.
Experts say these plans could remove healthy people from the individual marketplace. This would in turn drive up the cost of those plans because the group of people in the Obamacare marketplace would be sicker. The more expensive the plans get, the more unstable the Obamacare marketplace becomes.
"Loosely regulated association plans could charge lower premiums to healthy people, effectively leaving ACA marketplaces as high-risk pools," Larry Levitt, a senior vice president at the Kaiser Family Foundation, a nonpartisan health-policy think tank, tweeted in October after the executive order.
And because the association health plans wouldn't be as regulated, the plans could offer more limited coverage than plans covered by ACA regulations, Politico reports.
The move to institute association health plans is part of the executive branch's attempt to dismantle President Barack Obama's signature legislation after Congress's past attempts at comprehensive healthcare reform faltered in 2017.
Republican David Yancey won a seat in the Virginia House of Delegates over Democrat Shelly Simonds after a random drawing out of a bowl on Thursday.
The drawing keeps the GOP in control of the House of Delegates, with a 51 to 49 majority.
Yancey's victory makes the path to possible Medicaid expansion more difficult for Democrats in the state.
The composition of the Virginia House of Delegates, and possibly the future of thousands of Virginians' healthcare, was determined by a random drawing out of a bowl on Thursday.
The drawing that made Republican David Yancey the winner of the House seat over Democrat Shelly Simonds will give the GOP a slight advantage in the Virginia legislature and could affect the future of the Medicaid program in the state.
Virginia has so far not expanded the Medicaid program under the Affordable Care Act, despite repeated attempts from former Democratic Gov. Terry McAuliffe. Expanding the program would allow people making up to 138% of the federal poverty line to receive healthcare coverage through Medicaid, which could total as many as 400,000 Virginians.
A Simonds victory, which she appeared to have in hand after an initial recount last month, would have provided newly elected Democratic Gov. Ralph Northam with an easier path toward expanding Medicaid. Yancey previously voted against expansion.
Simonds is considering challenging the election results further. But if Yancey does indeed take the seat and Republicans come in control of both chambers of the legislature, expanding the program would become more difficult.
Expanding the program could still be possible under a Republican-controlled legislature, which had been expected before Democrats' wave of victories in the state in November. Northam has expressed interest in working on a bipartisan solution to expansion, and only a few Republican members would need to reach across the aisle to get it done.
“There are a lot of things we’d pay extra for a doctor to do,” she said. “This is not one of them.”
Just ask Christina Arenas.
However, doctors often choose to order imaging tests rather than drain apparent cysts, Levy said. “We’re so afraid the next one might be cancer even though the last 10 weren’t,” she said. “So, we overtest.”
In 2015, Dr. Dong Chang, the director of the medical intensive care unit at Harbor-UCLA Medical Center, a public hospital in Los Angeles, decided to see whether the care being delivered in his ICU was appropriate.
If the hospitals in Maryland and Washington with the highest rates of intensive care use had behaved more like those with lower use, it would save around $137 million, the study estimated. That’s the savings for fewer than 100 hospitals in two states. There are about 4,000 hospitals nationwide, suggesting that reducing unnecessary intensive care use could save billions of dollars a year. 
The future of American healthcare has taken on new dimensions over the last year as President Donald Trump and Republicans in Congress attempt to repeal Obamacare. But Oscar keeps pushing forward.
