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The Battle Over American Health Care: What's At Stake In The Senate's Bill


This is FRESH AIR. I'm Dave Davies in for Terry Gross, who's off this week. Nearly six months into the Trump administration, the nation is once again embroiled in a debate about health care as Senate Republicans seek to repeal and replace the Affordable Care Act, or Obamacare.

After weeks of crafting the bill behind closed doors, Majority Leader Mitch McConnell is trying to corral 50 Republican senators to vote for it. It's proving difficult in part because an analysis by the nonpartisan Congressional Budget Office found it would lead to millions more uninsured Americans and require many more to pay for their health care. Some conservatives don't like the bill because it leaves much of the structure of the Affordable Care Act in place. So far, McConnell doesn't have the votes to move the bill to the Senate floor for consideration. He'd hoped to have a final vote on the bill before the July Fourth recess but postponed action when it became clear he didn't have enough votes.

To help us understand the Senate health care bill and what happens if Republican efforts to repeal and replace Obamacare collapse, we called on Sarah Kliff. She's been covering health policy in Washington since before the Affordable Care Act was passed. She's now senior policy correspondent for Vox and co-host of their podcast called "The Weeds."

Well, Sarah Kliff, welcome back to FRESH AIR. When you talk to Republicans and ask them why the repeal of Obamacare is so urgent, they tend not to talk about the first several years of the Affordable Care Act but focus on the last couple when there have been rising premiums and a lot of insurers getting out of local market so people have less choice. This is a real thing, right? What has driven that? Why is that happening?

SARAH KLIFF: Yeah, that's certainly a real thing. I think it is undeniable that the marketplaces have had much less competition than the drafters of the Affordable Care Act had hoped for. They had expected these kind of new marketplaces where people could shop online and compare plans, that insurance companies would just flock to them. And the opposite's been true. We've seen a lot of markets that just have one health insurance company or two. I remember at some point President Obama, when he was selling this - he said it would kind of be like a Expedia for health insurance, and that has not been the case. If it was Expedia, you'd be going on, and there'd be one airline.

What has happened there is that insurance companies have not found these to be especially profitable and desirable markets. I think one thing that's important to keep in mind is that most health insurers - their biggest book of business is employer-sponsored coverage, the big plans that most of us in the United States are covered with. So the individual market is already, you know, a kind of small part of their book or business. And it was really an unknown. They didn't know how much people would cost in that marketplace, how many people would sign up.

So we've seen the people who sign up - they - there are fewer of them than was initially projected. They are sicker, which means that premiums have to go higher. So a number of health insurance companies have lost money on the marketplaces in 2014, 2015, 2016. And even before the election, you saw big health insurance plans like United and Aetna saying they didn't want to sell in this marketplace - better to cut their losses, get out and just focus on the thing they know to do best, which is sell health insurance to big companies.

DAVIES: So this is clearly a problem for people trying to use these health marketplace. Are there any steps that Republicans have taken either in the Congress or the White House that have made this problem worse?

KLIFF: Yes. One of the things that Republicans did in 2015 is they limited funding for a key program that was meant to stabilize the Affordable Care Act. This is something that Senator Marco Rubio led the charge on. Basically there was a health insurance program that was meant to limit the losses that a company would have in the marketplaces. The idea was, you know, these marketplaces are new. Insurance companies don't really know who's going to sign up, how to set prices. So for the first few years, we're going to, you know, like, bowl with the bumpers on. We're going to make sure that they can't lose too much money.

This is - if you ever heard Marco Rubio a few years ago talking about an insurance slush fund, this is what he was talking about. He was arguing that those bumpers shouldn't be there, that insurance companies should not get any of this help. And in 2015, he was successfully able to cut off a lot of funding for that program. And this - I've talked to a lot of insurance companies about the marketplaces, and they say this was really big - that they had kind of set prices thinking this money would be there. And all of a sudden, it was gone. So that is something that certainly affected the marketplaces and made them work less well than they would have otherwise.

There's also something happening right now that a lot of insurance plans say is really messing with their ability to participate, is making them think twice about whether they want to participate in the Affordable Care Act. And it's all this uncertainty here in Washington. It is really hard to commit to building a book of business around a market that Republicans are promising to repeal.

So when I talk to executives of health plans who sell in the marketplaces now, most of them sound like they want to stick with it. If they've made it this far, they feel like they are starting to understand the market. But they just don't really know what to expect in 2018, and they're worried about losing a lot of money. So all the uncertainty around this debate - it affects the current law that we have standing right now.

DAVIES: So let's talk about what's in the Senate bill that has - that the Republican leadership has come up with. The individual mandate, the requirement that everybody have health insurance - does it disappear?

KLIFF: It does disappear. So there is no individual mandate in the Senate bill. Instead it is replaced with a six-month waiting period, which, like the individual mandate, is meant to penalize people who don't have health insurance. So the whole goal of these policies is to give healthy people a reason to buy insurance because otherwise, if you're 25, relatively healthy, you might decide, you know, I don't need health insurance; I'm just going to sit it out. And premiums will go up for everyone else if lots and lots of young, healthy people make that decision. The individual mandate was meant to be a financial penalty you'd have to pay for making that decision.

With this waiting period, people who had a two-month break in coverage would have to sit out for six months before being allowed back into the market. So it's essentially saying, if you want to take a chance, if you want to have a break in coverage, there are going to be consequences later. You might get sick, and you will not be allowed back into the health insurance market for six months. So it's a different way of disincentivizing the same behavior that the mandate was aimed at, the behavior of sitting out of the insurance market.

DAVIES: OK. So people would not be required to have insurance. There would still be an individual market. Would there still be these government subsidies for people who need help?

KLIFF: There would, but they would be significantly smaller, and they would purchase less-generous health insurance coverage. So for low-income people who rely on the marketplace right now, they would generally get less financial help, and they would be enrolled in plans that provide less-generous coverage. Or, you know, that typically means higher deductibles and higher co-payments.

DAVIES: So under the Affordable Care Act, there were some basic requirements that every health policy had to meet, right? You couldn't just sell people junk insurance and sell them at a bargain price. What happens to those requirements that maintained some level of coverage equality?

KLIFF: So there's a lot of elements of this. I'll focus on two in particular as they relate to the quality of health insurance. One is the essential health benefits package, which is this suite of benefits that every health insurance company is required to cover under the Affordable Care Act. This includes things like maternity care, mental health services, which insurance companies in the individual market often left out before the health care law because they were quite expensive and drove up premiums. Under the Senate plan, states could apply for a waiver from that requirement. They could, you know, say in our state, you don't have to cover those things. We want to set this package differently. So that's kind of one bucket of changes, that you could see the actual benefits that are covered change in the coverage.

The other one is a little wonky and complex, but it actually matters a lot, and it has to do with the generosity of health insurance - not what it covers but what percent of bills it covers - so how much the average enrollee pays versus how much the insurance company kicks in. And one of the really key changes in the Senate bill is that the subsidies will purchase less-generous health insurance. The subsidies under the Affordable Care Act right now - they are meant to make affordable health insurance plans that cover 70 percent of the average enrollee's costs. So the idea is the insurance company kicks in 70 percent. You the patient, through your deductibles and co-payments - on average, you're kicking in 30.

Under the Republican bill, the plans they're subsidizing cover 58 percent of the average enrollee's costs. So that means you are kicking in more deductibles, more co-payments, more co-insurance. And I think there are some fair concerns with this bill about, what does that mean for low-income Obamacare enrollees? Could they afford to have these less-generous health insurance plans? Would they even want to buy these less generous health insurance plans?

DAVIES: So are there examples of what the impact might be on, you know, poor and working people or older people?

KLIFF: Yeah, there certainly are. This is something the CBO actually spells out in pretty clear detail. So to give you a few examples from that report, they look at how much, like, a mid-level health insurance plan would cost for someone who earns $26,000. So kind of on the lower end of the income spectrum. For someone who is 64, right now under the Affordable Care Act, they're spending $1,700 a year on their premiums out of pocket.

Under the Senate bill, that would rise to $6,500 per year. Again, we're talking about someone earning $26,000 being asked to put $6,500 dollars of their post-tax income towards their health insurance premiums. So I think this is why the CBO looks at these numbers and says, a significant number of those people are going to decide not to purchase coverage.

DAVIES: And what does that cover, even if they pay the 6,500?

KLIFF: Yeah, so for a plan like that, it probably would have a pretty significant deductible, like, somewhere in the 3 to 6,000 range, although we don't have exact numbers on that. And it would cover the essential health benefits, these things like prescription drugs, hospital visits, doctor visits. But let's say, you know, for the sake of argument, the deductible's $4,000 or so.

That's on top of the $6,500 you are already spending on your premiums. And you're someone earning $26,000. It is hard to see that person deciding that this health insurance plan that, you know, could end up with $10,000 in health spending between the deductible and the premiums, feels like a good deal.

DAVIES: Are costs particularly higher for older people in the Senate bill?

KLIFF: They really are. You know, and this goes across the income spectrum where older Americans are asked to spend a larger percentage of their salary on health care. There is one other statistic from the CBO report, which also looks at people slightly higher up the income scale, people who earn $56,000. For a 64-year-old who's at that income level, under the current law, they're expected to spend about $7,000 on premiums.

Under the Senate bill, that would rise to $20,000. And again, I'll remind you, this is someone earning $56,000 a year. So we're talking about more than a third of their income is what CBO estimates they would have to pay just in their premiums to get coverage under the new law.

DAVIES: Is there any explanation for why they seem to be so much higher for older people?

KLIFF: Yeah. They're changing the definition of what counts as affordable. And they're tethering it to age. So one of the things the Affordable Care Act does and the Senate bill does is it sets an amount for what percent of your income they feel like is fair to spend on insurance, what someone earning 20,000 or 40,000 or $60,000 a year could afford.

And one of the unique things about the Senate bill is it says that we think older Americans can afford to put a larger percent of their salary towards health insurance premiums. So it's the raising of those caps for just older Americans. One of the differences with the Affordable Care Act is it doesn't matter how old you are.

The cap stays the same for someone who's 21 or 64 as long as they're at the same income level. The Senate bill is a bit unique because it raises that cap for just the oldest Americans.

DAVIES: Have they offered a policy explanation for that, why older people are considered to be able to spend more of their income for health insurance?

KLIFF: So the idea is to tether what people are paying a bit more closely to how much they actually cost. The Affordable Care Act had policies that really compressed what people pay out of pocket where older people paid less than what their medical bills really were, younger people paid more. This is kind of a roundabout way to have older people pay premiums that are more in line with how much their medical bills actually cost.

And on the converse side, this lets the bill lower premiums on younger people and kind of give them more of an incentive to join the market because they will be doing less subsidizing of the higher bills that older insurance enrollees typically have.

DAVIES: That was an example involving an older person. Does the report give an example of, I don't know, someone who's middle aged and poor?

KLIFF: It does. It does. So for someone who's middle aged, the changes are less extreme. You can look at someone who's 40 years old and earns $26,000. This person would see their premiums - and this is annual premiums, again - rise from 1,700 under the current law to 3,000 under the Senate bill. So you're seeing an increase of $1,300 for a 40-year-old at this income level and an increase of more than $4,000 for a 64-year-old at the same income level.

DAVIES: Right. And the Congressional Budget Office has run some numbers, has done an analysis of anticipated consequences here. What do they find in terms of, you know, what people can afford and what kind of insurance they will get if this plan were enacted?

KLIFF: So they find a lot of people lose health insurance. And one of their findings is that low-income people, a lot of them won't purchase coverage. They will look at these choices in front of them and they will say, it's not worth it to spend money on a monthly premium to purchase a plan that might have a deductible of $6,000 or so, particularly if you're someone earning, let's say, $11,000.

It just doesn't seem like there's a lot of value in paying for that plan or a lot of financial protection. So the Congressional Budget Office, they estimate that 22 million Americans will lose coverage by the end of the next decade. And most of those people would be low-income Americans.

These would be people who are currently enrolled in Medicaid expansion, which is phased out in the Senate bill, or people who use the marketplace with tax credits, who would still get a tax credit, but because it's less generous, might decide not to use it.

DAVIES: And under this bill, can insurers reject people who have preexisting medical conditions?

KLIFF: They cannot. So I've seen a little bit of information floating about there saying they can. That is not in the Senate bill. You know, that being said, I think it still creates a landscape that is difficult for Americans with really significant medical issues. It goes back to getting rid of that essential health benefits formula because you can't reject people, but you can stop covering expensive benefits, the exact type of benefits that would attract, you know, people who have really significant health care needs.

So you could see under the Senate bill, for example, a state waving out of the essential health benefits and no longer covering, let's say, prescription drugs, for example. And all of a sudden, that plan, you know, is still offered to people with preexisting conditions, but it is a lot less attractive to those people.

DAVIES: Sarah Kliff is a senior policy correspondent at vox.com. She's continuing to focus on the efforts in Congress to repeal the Affordable Care Act. We'll continue our conversation after a short break. This is FRESH AIR.


DAVIES: This is FRESH AIR. And if you're just joining us, we're speaking with Sarah Kliff. She's been reporting on health care policy in Washington for many years. She's currently a senior policy correspondent for vox.com. She also co-hosts a policy-oriented podcast called "The Weeds." Let's talk about the Medicaid expansion, which has insured millions of Americans under the Affordable Care Act.

What happens to the Medicaid expansion under the Senate bill?

KLIFF: The Medicaid expansion would be phased out over a number of years. So right now there's an estimated 11 to 14 million Americans in Medicaid expansion. Some of the estimates are a little bit different. And this bill would really ratchet down funding for that program over the course of four years until the point that it essentially is ended.

People who are on Medicaid expansion right now would be grandfathered in. So if you're someone who is enrolled in that program, the program is phased out, you can stay on it. But if you ever fall off your coverage, there's not going to be a way to get back onto it. So you really see this really key Obamacare program responsible for more than half the coverage gains in the law being ended under the Senate bill.

DAVIES: Right. And if you stayed on the program, you'd still get the - the state would still get the generous federal funding to keep you on Medicaid?

KLIFF: If you are someone who is already on the program, they would. But if you are someone who is signing up new to the program, you would not get that funding.

DAVIES: So over time, the number of people would diminish

KLIFF: Yes. So what's going on in the background of the Senate bill is that the federal government each year, between 2021 and 2024, will be phasing down what percent of this Medicaid program that it covers, what percent the federal government finances. And it would ratchet down - right now it's at 95 percent. It would fall 90, 85, 80, 70.

And the expectation that the Congressional Budget Office has is that many states will stop participating in the Medicaid expansion as this funding falls because they feel like they can't fit it into their state budgets.

DAVIES: When the Congressional Budget Office looked at the bill, what did they think would be the result of this restructuring?

KLIFF: So they think that significantly fewer people would have Medicaid. Between the end of the expansion and these changes to the overall funding, they estimate that a decade from now, 15 million fewer people would have Medicaid. And CBO expects that states would react to these cuts in a number of ways. They would, you know, stop participating in Medicaid expansion, they would probably try and do some streamlining, try and find whatever efficiencies they can in the program.

But they would also probably cut out some benefits. They would probably stop covering as many people, and they would probably stop covering as many services as they currently do.

DAVIES: So when you look at what the Congressional Budget Office concluded when it looked at the details here, overall, what does it say about whether this cuts costs to consumers and provides better care?

KLIFF: I think it depends a lot on which numbers you focus on and which consumers you're talking about. So one of the things the CBO does find is that premiums in the individual market would go down significantly under this bill. I think it's by about 30 percent or so. But part of that would be the result of insurance covering fewer benefits and a lot of sick people dropping out of the marketplace, particularly a lot of older Americans dropping out of the individual marketplace because they can no longer afford coverage.

The Congressional Budget Office also estimates that, yes, premiums would be lower, but out-of-pocket spending, things like deductibles and co-insurance and co-payment, those would be significantly higher. So, you know, it depends on, you know, which way you want to look at this. And we hear a lot of Republicans talking about the lower premiums that CBO is projecting.

But it looks like overall, when you kind of take this, you know, in totality, that the Republican bill, the Senate bill, is one that asks low income Americans to spend more out of pocket on their own health insurance.

DAVIES: Sarah Kliff is senior policy correspondent for Vox. After a break, she'll talk about the secretive process used to draft the Senate bill and what happens if it doesn't pass. And David Edelstein reviews Edgar Wright's new film "Baby Driver." I'm Dave Davies, and this is FRESH AIR.


DAVIES: This is FRESH AIR. I'm Dave Davies in for Terry Gross, who's off this week. We're talking with Sarah Kliff about the Senate health care bill. Majority Leader Mitch McConnell had hoped to get it to a vote before the July 4 recess but has postponed action because he can't get enough support for it to pass. Sarah Kliff is senior policy correspondent for Vox and co-host of its podcast "The Weeds."

When we left off, Kliff had explained that the Congressional Budget Office found the bill would leave millions more uninsured and would increase health care costs for many Americans, especially older people. You've been covering this issue in Washington for a long time. You must talk to Republican staff and senators. What do they say when these questions are raised about whether people are going to end up paying a lot more and getting poorer coverage?

KLIFF: Yeah, that's been one of the, you know, interesting and different things from covering the last health care debate, which I did. You know, back then in 2009 and 2010 when I talked to Democrats about their health care bill and asked them, you know, what's the point of all of this, they would say, we want to increase coverage and reduce costs. It would be some variation on that line. You know, when I and my colleagues at Vox talked to Republican senators over the past few weeks and ask, you know, what's the goal of this whole thing? We've heard back from multiple Republican senators. The goal is to get 51 votes. The goal is really less about policy and more about passing something.

I think when, you know, we talk about particular things in the bill, you know, mostly the Republican reaction to the CBO report was very negative. There were a lot of reporters on Capitol Hill shortly after it came out. And nobody - no senators really seemed to make - want to make the case that this was a good score for them, that this showed positive reforms. I think it explains why the party has struggled to move towards a vote this week.

I think one of the things that conservative members of the Republican Party like is the deregulation of the health insurance market. They would argue that these, you know, benefit mandates are driving up costs. Yes, this will mean higher prices for some, but it is not fair that everybody has to pay for this kind of robust set of benefits, that people should be more free to pick and choose what kind of benefits they want in their health insurance coverage. So I think you hear that kind of rhetoric from Republican legislators talking about why it would be a good thing to move in the direction that the Senate bill does.

DAVIES: Right. I mean, you know, we do hear, you know, proponents of these changes, say, you know, the answer here is found in the power of markets and the creative genius that arises from competition. When you let markets work, they will deliver products to people - good products at a good price. I'm wondering; are there any specific ways that they argue that this set of changes will actually result in the kind of competition that will benefit people? I mean it's sort of - it's one thing to make the point as a general principle. It's another - this is what's wrong. This is what will be different.

KLIFF: You know, you don't hear as many of those arguments as you would expect. I think one of the things that's been a little bit telling in this debate is a lot of conservative health policy experts haven't been really excited about the bills that have been coming out of Congress. They haven't been saying, like, yes, this is the things we've been wanting to do once we get into legislative power, that this is a good way to reform the system. I think there are certainly a lot of ideas out there on the conservative side, you know, for how they would like to move to a more free-market system.

But one of the things I think you'll see a lot of conservative senators and thinkers grapple with is this bill actually keeps a lot of the structure of the Affordable Care Act in place. You have the subsidies, the requirement that insurance companies accept everybody, you know, the essential health benefits unless you decide to pursue a waiver to them, that this actually still is a pretty regulated health insurance market.

And I think that is one of the kind of notable things about the legacy of the Affordable Care Act - is as much it is - as much as it is kind of derided and detested by Republicans, it has proved awfully difficult to write a bill that would get rid of it entirely.

DAVIES: Because some of these benefits are popular, right?

KLIFF: Yeah. I think people generally, you know, like the idea of getting health insurance. People who have gained coverage say they're pretty happy with their coverage, particularly in the Medicaid expansion. The people who have Medicaid seem to like their coverage just as much as people who have employer-sponsored coverage. I think the biggest gripe I hear talking to Obamacare enrollees is that their cost-sharing is too high, that the deductibles are too high, their co-payments. They have this health insurance plan, but they feel like they can barely use it because they have to spend so much money each time they go to the doctor.

And one of the interesting splits we've seen is that a lot of conservative thinkers actually think deductibles should be higher because that's going to incentivize people to be good shoppers, that we will make smarter health care decisions when we are, you know, deciding to spend our money versus someone else's money. But you've seen kind of this two-sided approach from Republican legislators who you will often see on television deriding the deductibles and Obamacare, saying these deductibles are too high; Americans hate them. But now they've introduced this bill that would increase deductibles.

So it is a lot harder to make sense right now of what actually is the goal of this bill, what Republicans are trying to do with it beyond coming up with something to repeal and replace the Affordable Care Act. But I will say, at the end of the day, the agreement seems quite clear that these plans will cause fewer people to have health insurance. And it'll be a fewer number in the millions. The debate is how many millions. It's not whether people will lose health insurance.

DAVIES: Let's talk a little bit about the process that got us here and where we're going next. A lot of attention was paid to the secrecy that characterized the drafting of this bill. There were complaints from Democrats and some Republicans. Do we know who actually worked on the drafting, whose work this is?

KLIFF: We don't know for sure. The best we can tell is that it is a lot of aides to Senate Majority Leader Mitch McConnell. Also the Senate Budget Committee and their staff seems to have been quite involved. But one of the kind of surprising things in covering this debate was you did have a working group of 13 senators who were supposedly the ones pulling this bill together. But when you would talk to them, they often wouldn't know who exactly was writing it. So it seems like it was a very held-closely-to-the-chest drafting process with a smaller number of Republican health policy advisers up in the Capitol involved.

DAVIES: You know, a lot of legislation is drafted privately - I assume most of it. Somebody's got to, you know, come up with the first language, and that's typically done behind closed doors. But the legislative process provides for open debate and public hearings once the legislation is drafted and submitted. You know, there's a process, right? I mean there are public hearings at which all of the affected parties can analyze its provisions and look at its potential impact. In this case, are there plans for any public hearings over this proposal?

KLIFF: There are not. Senate Majority Leader Mitch McConnell has been very clear from the start of this process that he does not want to have hearings on this bill. He does not want it to move through the normal committee process. The plan from the get-go has really been to introduce the bill, to have the CBO score come out, to have a floor debate and then to vote on it.

And initially, we were looking at a very, very fast timeline of the bill being introduced on a Thursday, a CBO score on a Monday and a vote the next Thursday. It looks like Senate Republicans will not be able to get this done quite so quickly. But one other thing that's really been remarkable about covering this process is how little time it has left for public input and analysis. We're talking about in the original kind of timeline just one week between the bill being made public and a desired vote.

DAVIES: You know, I have to say. I mean in the Philadelphia City Council and I bet legislative bodies all over the country, that would just be flat-out illegal. There have to be public hearing. Isn't that typical?

KLIFF: Yeah, and it's very - it was surprising, and it was - it's not a great way to legislate, I would argue. One of the things that, you know, we saw happening in - just in the past, you know, week or so that we've known about this bill is people are finding different provisions. They're noticing, hey, if you do this thing, it's going to cause this problem. I hear from insurance industry sources who say, you know, we're worried about this small business thing, but we don't think there's enough time to fix it. That waiting period we talked about earlier - that wasn't even in the first draft. That part was missing, and they added it in a few days later.

So it really does not - there is a reason to have a public open process, and it's mostly to get feedback and to improve your legislation and catch those kind of unintended consequences that you might not see when you're in the room on Capitol Hill drafting this bill. And there hasn't been much time for that in this process. There's, you know, only been a week to provide feedback on this bill.

DAVIES: You know, one of the things you see a lot of Republican senators saying is, well, you know, the Democrats passed Obamacare on a strictly partisan vote, and maybe this isn't great but, you know, they did it, and now we're going to do it. How does this process compare to the drafting and enactment of the Affordable Care Act?

KLIFF: So the process is undeniably more rushed and less public. You know, I covered that last health care debate. During the healthcare debate, there were 44 public hearings, roundtable meetings on Capitol Hill, 22 of those in the Senate, 22 in the House. A lot of these really clustered at the start of the drafting of the bill, so they were really kind of an information-gathering activity trying to figure out, what's the best way to structure this policy? How do we incentivize people to get health insurance? How do we decide what is good health insurance? So there was a lot of time to understand what the bill was, how it worked, what it did.

I think it is certainly true that the process became a partisan process about halfway through. When the Democrats realized they were not going to get any Republicans to support their bill, they essentially stopped talking to the Republicans and started working amongst themselves. And I think it's actually, you know, instructive to look at where that has gotten them. And the risks Republicans run of repeating that process - is that we've seen with the Affordable Care Act. If you pass a bill on a party-line vote, you really set it up for aggressive attack and obstruction. And the other party feels absolutely no stake in the success of the legislation.

So I think if Republicans, you know, decide to follow this path, that they are signing up for the exact same thing - that Democrats are not going to be helpful or willing implementers of a law that they felt, you know, was completely rushed and that they were shut out of the process.

DAVIES: Sarah Kliff is senior policy correspondent at vox.com. We'll continue our conversation in just a moment. This is FRESH AIR.


DAVIES: This is FRESH AIR, and we're speaking with Sarah Kliff about health care policy. She's been reporting on the health care debate in Washington for many years. She's a senior policy correspondent for vox.com. She also co-hosts a policy-oriented podcast called "The Weeds."

You know, President Trump said at some point that he thought that the bill that the House passed was mean and that he'd like from the Senate a bill with heart. What role is the White House playing here?

KLIFF: So we know the White House isn't playing a huge role in policy. Everything - you know, our reporting and others' reporting suggests is that they're leaving the actual bill-writing to Congress. Their main objective is to get something passed, to get a win. You can see that President Trump, you know, is very excited to get something done on health care. He held that Rose Garden ceremony for the House bill after it passed, which was somewhat unusual. Usually you save the Rose Garden for when something is signed into law, not after it goes through one chamber. But then like you mentioned, you know, he called that bill mean to a number of senators that he was meeting with.

I think so far we've seen the White House's role really be in trying to lobby senators into saying yes, trying to make the case for why they need to stick with Obamacare repeal. I think they are the ones on the political side, you know, trying to push this forward as much as they can while really taking a back seat on the policy details.

DAVIES: You know, among Republican senators, there are some who say they want different kinds of bills and then some who say, we're not going to rush into this; we need time to consider this thoughtfully. Does Majority Leader McConnell - what's next procedurally? Does he need to get a vote to put this on the Senate calendar and get it considered?

KLIFF: So the timing is not really clear right now. What would need to happen - the steps that would need to happen is he would have to offer a motion to proceed, which is the first step towards a vote. And he would have to get half the chamber to support that motion to proceed. And that's actually where this week a lot of the debate isn't about, will I support the bill; will I not? A lot of senators are commenting on, will I even let the debate start? And a lot of - and a - not a lot, but a handful are saying, we're not ready to start that debate.

So you'd have this motion to proceed. You'd have some number of hours of Senate debate. We don't know exactly how many. You would likely also have amendments being offered during this debate. Again, we don't know the exact procedural specifics. And then this would lead up to a vote. So we're talking about a day or two process.

But right now Mitch McConnell has some decisions to make about how he wants to handle this. He was hoping to get a vote this week. That now looks quite unlikely. The Senate will go on recess for the July Fourth holiday, come back the week after July Fourth. And then, you know, Senator McConnell has a decision on his hands. Does he want to keep pushing on this health care effort, revise the bill to get more senators behind it? Or does he want to move on to another priority like tax reform that is also quite high on the agenda?

DAVIES: So if Congress is unable to agree on a plan to repeal and replace Obamacare, I mean they move on to other priorities. What does that mean for the health care structure we're left with and people who need health care from these private insurance exchanges?

KLIFF: Right. At the end of the day, if Obamacare is left standing, the Trump administration is charged with running a program it has tried to repeal. I think for people on Medicaid, not much changes, that their coverage probably continues as it has been. That part of the program seems to be working quite well.

The marketplaces, however, are part of the program that's at significant risk. There are an estimated 49 counties in the United States with zero health plans signed up to sell coverage in 2018. These are mostly rural counties in Ohio, in Indiana and in Missouri. So they have some challenges on their hands.

The Trump administration has been talking about how Obamacare is collapsing, how it's falling apart, the high premiums. But most survey research suggests voters are going to associate those problems with the Trump administration now. That once you, you know, step into the White House and you take ownership, this is your bill. And you need to deal with any sort of problems or positives that are showing up in it. So I think you can expect some difficult conversations about, how do they want to run the marketplaces? Do they want to let these marketplaces work?

One of the things we've seen a lot in the administration's press strategy is to really highlight all the problems in the Affordable Care Act, say this insurance company quit or that insurance company is raising rates and use that to make the case for why we need to do repeal. But we could end up in a situation where there is no repeal bill, and the Trump administration will have to make decisions about, you know, how do they want to run this program?

DAVIES: One thing I saw attributed to Mitch McConnell in recent days was a statement to the - to his fellow Republicans to the effect is, look; if we can't work this out and pass a bill, you're going to leave me in the position of going to talk to Chuck Schumer and the Democrats. I wonder what you make of that.

KLIFF: (Laughter) Yeah, well, and I mean it is - it again speaks to how much of a political football this has become because when he says, you know, if we don't pass this, it's not like we'll miss a great policy achievement. But it's, oh, we'll have to work with the Democrats. I think what he's talking about there is that Congress has been quite concerned about the stability of the insurance markets. And in that Senate bill, there are actually a few policies meant to make Obamacare work better in 2018 and 2019 before the new Republican system would kick in.

And I think what he is warning them is that, you know, we have to make Obamacare work. There isn't any chance to blow it up if we don't come up with our own system. And I think that is something that is going to weigh on the minds of senators as they go home for this July Fourth recess - is that they, you know - I think there's a lot of concern in the caucus about the plan, the coverage lost.

But at the end of the day, a lot of them have spent the greater part of a decade running on this promise to repeal this bill, not to work on tweaking and improving the Affordable Care Act. And I think that is the issue Senator McConnell is trying to raise in their mind - that, you know, if you don't do this, then it's the Affordable Care Act we're stuck working with.

DAVIES: Well, Sarah Kliff, I'm sure you'll stay on top of it for us. Thanks so much for speaking with us.

KLIFF: Yeah, thank you for having me.

DAVIES: Sarah Kliff is senior policy correspondent for Vox and co-host of its podcast called "The Weeds." Coming up, David Edelstein reviews the new film from Edgar Wright, who directed "Shaun of the Dead." This is FRESH AIR.

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