Does the Alexander-Murray bill adequately protect vulnerable groups?

The changes to the ACA's Section 1332 state innovation waivers in the Alexander-Murray marketplace stabilization bill  have broad support, having been proposed by multiple HELP Committee hearing participants and endorsed by bipartisan outside advocates including  former acting CMS director Andy Slavitt, one of the ACA's most vocal defenders. These include providing for an expedited waiver process, an emergency waiver process, and the creation of "cookie cutter" waiver templates that multiple states may opt to adopt. (There are dissenters, however, as discussed below.)

Also a matter of broad consensus: easing the terms by which states meet the requirement that a waiver proposal be budget-neutral by 1) allowing states to combine Section 1332 waivers with Medicaid and CHIP waivers and using savings from one to offset extra spending on another, and 2) considering budget impact over the 6-year term of the waiver and a ten-year budget plan.

There is one alteration, though, that gets to the crux of the debate over state flexibility, and was probably a matter of intense negotiation. That is a change to the so-called "guardrails" pertaining to quality and affordability of coverage.

How could Patty Murray "thread the needle" with Lamar Alexander?

Ever since the Cassidy-Collins bill was introduced in January, I've thought that Democrats should engage with Republicans in Congress who were willing to leave the ACA's taxes and core benefits intact. Cassidy-Collins didn't do that, but I thought it came close enough to be a basis for talks.

Triage was the byword. If a handful of the dozen-odd Republican senators who were then expressing qualms about repeal of the Medicaid expansion in particular could be engaged in compromise negotiations, I thought, that would lessen the chances of passage for a bill that would uninsure tens of millions -- as would the AHCA, the BCRA, and now Cassidy-Graham.

Events have almost proved me wrong. The prevailing Democratic strategy -- we'll talk about fixes when they give up on repeal -- has almost worked. Three repeal bills failed in the Senate. Lamar Alexander, HELP Committee chaired, has held hearings on a bipartisan bill to stabilize the individual market.  And on the other end of the equation, Cassidy -- who seemed like a possible partner since he wanted to preserve ACA taxes and so something like its scale of benefits -- is now a driving force behind a bill that would zero out ACA benefits and lay waste to Medicaid.

Still, ironically, we're at a point again where I'm tempted by similar logic: if Patty Murray and other Democrats engage with Alexander and come up with a compromise stabilization bill, that could blunt the drive toward Cassidy-Collins passage. Would co-sponsors of a stabilization bill, led by Alexander, turn around and vote for Graham-Cassidy?

What price will Republicans extract for CSR funding and reinsurance?

If the current glimmers of bipartisanship in healthcare legislation take on any sustained shine, the primary agenda for Democrats is obvious: appropriate funding for Cost Sharing Reduction payments and for some kind of reinsurance program to replace the program that expired in 2017.

The first is simply a matter of ending sabotage: CSR is integral to the structure of the ACA marketplace and incorporated in its budget baseline. Republicans have simply exploited a drafting error to destabilize the individual market. As for reinsurance, Republicans made its necessity manifest by including generous "stability funding" in the main House and Senate "healthcare" bills -- in fact, overly generous funding designed to compensate for their various disfigurements of the market (e.g., repeal of the individual mandate and measures to reintroduce medical underwriting and non-comprehensive insurance).

To have any real hope of getting these measures passed in a Republican Congress, however, Democrats are going to have to face up to the question: What pound of flesh will they let Republicans extract as payment for these essential, common-sense fixes? It's a foregone conclusion from a progressive point of view that changes Republicans will demand will not improve the market. What concessions might actually win passage and do less harm than the fixes will do good?

Repair, not replace -- rebranding, or real change? Watch the Medicaid expansion

The battle over ACA repeal-or-whatever is going to go through a lot of twists and turns and bold assertions that will fade like morning dew. Still, the latest Republican messaging and positioning seems at least potentially significant. From The Hill's Peter Sullivan:

Key Republican lawmakers are shifting their goal on ObamaCare from repealing and replacing the law to the more modest goal of repairing it...

“I'm trying to be accurate on this that there are some of these provisions in the law that probably will stay, or we may modify them, but we're going to fix things, we're going to repair things,” House Energy and Commerce Committee Chairman Greg Walden (R-Ore.), a key player on healthcare, told reporters Tuesday.

Hmmmm...Team Trump queasy about ACA insta-repeal?

I credit nothing said by Team Trump...but this does not sound like ACA repeal:

“The enrollment numbers announced today show just how important health care coverage is to millions of Americans,” said Phillip J. Blando, a spokesman for the Trump transition team. “The Trump administration will work closely with Congress, governors, patients, doctors and other stakeholders to fix the Affordable Care Act’s well-documented flaws and provide consumers with stable and predictable health plan choices.”

A managed Medicaid bailout for repeal-and-delay Republicans

A week ago I suggested, in a kind of desperate good-Trump fantasy, that if Trump really wanted to fulfill his campaign promise to replace the ACA with "something beautiful," he could replace the ACA marketplace with a managed Medicaid buy-in for anyone who needed it.

Earlier this week, Michael Sparer, Chair of Columbia's Mailman School of Public Health, published in NEJM a somewhat akin proposal that could serve as both a basis for permanent compromise and a stopgap if we end up in "repeal-and-delay" limbo. Rather than creating a "fallback" public option from scratch, as President Obama and others have proposed,

A better idea, I believe, and one that could conceivably lead to a political compromise, is to rely on Medicaid managed-care plans to offer an exchange plan wherever they operate where there would otherwise be only one participating insurer. This strategy could work even if ACA premium subsidies for exchange enrollees were eliminated and replaced by some alternative version of tax credits or rebates.

That too might seem like a pipe dream, in that it requires constructive Republican action to keep people insured, not to mention expanding the Medicaid expansion. But maybe not! Austin Frakt's* reading of the political tea leaves suggests that some kind of stopgap staving off total collapse may become the new normal. Reacting to Senator Lamar Alexander's forecast that Republicans might need six years to forge an alternative that could overcome a filibuster, Frakt writes:

Well, Ezra Klein, Republicans may not have "plan" to save insurance markets after King. But they may deal

Republican Senators Orrin Hatch Lamar Alexander John Barrasso are out today with a lightly sketched "plan" to salvage premium subsidies credited through the ACA's federal exchange if the Supreme Court rules for the plaintiffs in King v. Burwell.  The proposal closely resembles the  possible post-King negotiation that former HHS Secretary Michael Leavitt outlined to me. Here's Hatch et al:

First and most important: We would provide financial assistance to help Americans keep the coverage they picked for a transitional period. It would be unfair to allow families to lose their coverage, particularly in the middle of the year....

Second, we will give states the freedom and flexibility to create better, more competitive health insurance markets offering more options and different choices. Republicans understand that what works in Utah is different from what works in Tennessee or Wyoming. We want to give states the time and flexibility to design health-care systems that work for them, not for the bureaucrats in Washington.

People who live in states that have state exchanges will continue to be subject to Obamacare’s costly mandates and rules, along with the subsidies. But their states could also have the benefit of our solution. Every state would have the ability to create better markets suited to the needs of their citizens.

And here's Leavitt last week:

Lamar Alexander writes a short history of the Obama presidency

After succumbing to reason and announcing that he'll vote for the New START treaty, Lamar Alexander received a thank you call from Obama.

"It was good,” Alexander said of his talk with Obama. “I asked him how he keeps playing with basketball with people who hurt him. He said he beats them.”

I'd like to think that right there is history's verdict, circa, say, 2030, on the Obama presidency.