Senate Republicans include repeal of Obamacare’s individual mandate in the tax bill

“The move to tuck the repeal of the so-called individual mandate into the tax overhaul is an attempt by Republicans to solve two problems: math and politics. Repealing the mandate, a longstanding Republican goal, would save hundreds of billions of dollars over the next decade. That would free up money that could be used to expand middle-class tax cuts or help pay for the overall cost of the bill, which can add no more than $1.5 trillion to the deficit over 10 years. It could also help secure the votes of the most conservative senators, enabling lawmakers to pass the bill along party lines.
If it becomes law, the repeal would save more than $300 billion over a decade but result in 13 million fewer Americans being covered by health insurance by the end of that period, according to the Congressional Budget Office. Republicans said on Tuesday that they would use the savings — which stem from reduced government spending to subsidize health coverage — to pay for an expansion of the middle-class tax cuts that lawmakers had proposed.
On Tuesday evening, the chairman of the Senate Finance Committee, Orrin G. Hatch, Republican of Utah, was expected to release an amendment that would add the repeal of the mandate to the Senate’s tax plan. On the House side, members of the Rules Committee met Tuesday evening, one day earlier than scheduled, to pave the way for a floor vote on Thursday. (A)

“Now it turns out that getting rid of the mandate could help Republicans as they tackle the difficult math of tax reform. According to a recent Congressional Budget Office estimate, eliminating the mandate could lower the deficit by $338 billion over a decade. A third of a trillion dollars can help pay for a lot of tax cuts. Which is why Senate Republicans, trying to find funding and keep their promise to dismantle Obamacare, are now vowing to add a mandate repeal to their tax bill. (B)

“President Donald Trump said Monday that he will nominate former pharmaceutical executive Alex Azar as secretary of the U.S. Health and Human Services Department….
Azar in February, during an interview on CNBC in February, said “The remarkable thing here is Obamacare is failing completely on its own terms.”
Speaking about what was then a prospective Republican Obamacare repeal-and-replacement bill, Azar said there was a consensus among Republicans and Democrats that the government should play a role in expanding insurance coverage and subsidizing its purchase by individuals. But he suggested that the way to do that was one other than Obamacare’s system.
And Azar was firm in his prediction that the GOP bill would become law within months.
“There will be a piece of legislation passes this year that is called ‘the repeal of Obamacare,’ ” Azar said. “I don’t know what’s going to be in the substance of it, but there will be a piece of legislation that says that.”
Azar was wrong about that. Republican leaders in Congress repeatedly fail to pass repeal-and-replace bills, despite controlling both the Senate and the House.
Azar has previously said he does not believe the expansion of Medicaid has been successful, saying he would have preferred to use government money through “private-sector vehicles” to deliver health care.” (C)

“Vice President Mike Pence is exerting growing influence over the American health care system, overseeing the appointments of more than a half-dozen allies and former aides to positions driving the White House’s health agenda.
On Monday, President Donald Trump nominated Alex Azar, a former Indianapolis-based drug executive and longtime Pence supporter as Health and Human Services secretary. If confirmed, Azar would join an Indiana brain trust that already includes Centers for Medicare & Medicaid Services Administrator Seema Verma and Surgeon General Jerome Adams. Two of Verma’s top deputies — Medicaid director Brian Neale and deputy chief of staff Brady Brookes — are former Pence hands as well, as is HHS’ top spokesman, Matt Lloyd.
Yet another Pence ally — Indiana state Sen. Jim Merritt — is in the running to be White House drug czar.
Pence’s sway with the policymakers controlling Obamacare, Medicare and Medicaid comes at a time when Trump and Congress continue to struggle with the repeal of the Affordable Care Act. But Pence and his cadre are driving a national agenda dominated by the kinds of conservative, anti-regulatory policies he embraced as Indiana governor.” (D)

“Azar has called Verma “one of the leaders in reinventing Medicaid.” He shares her view that the health care program for low-income Americans has to be put on a more “sustainable” financial footing, and states should be given more accountability and responsibility for running the joint federal/state program.
On the individual insurance market, the other major aspect of health care restructured by the Affordable Care Act, Azar has echoed the Trump administration’s view that the market is failing.
“Obamacare is going down right now,” Azar told Fox News in July. “It is an almost impossible market to do from an insurance perspective.””
He’s said the regulations need a “top-to-bottom comprehensive rewrite” to impose “as much free market, localized flexibility as humanly possible.” (E)

“There’s one set of eyes that President Trump’s appointees absolutely cannot ignore as they set about trying to reshape Obamacare and enact sweeping new changes to the government’s health-care programs.
They belong to Joe Grogan, director of health programs at the White House’s Office of Management and Budget.
You’ve probably never heard of Grogan — but you should know who he is. Grogan, perhaps more than any other member of Trump’s administration, holds the power to nix or give the nod to hundreds of regulations shaping how the federal government runs Medicare, Medicaid, the Affordable Care Act marketplaces, the FDA, the CDC and all the other sub-agencies contained within the sprawl of the Department of Health and Human Services.
Without Grogan’s assent, for example, the Centers for Medicare and Medicaid Services wouldn’t have been able to essentially wipe out steep and long-term drug discounts received by charity and rural hospitals. Last month’s rule change to the 340B program — viewed by many as rather gutsy on the part of CMS because it infuriated hospitals — had to get past Grogan’s desk at OMB, just like every other regulation change the administration wants to make.” (F)

“As Republican lawmakers worked on Monday toward a delicate compromise on a $1.5 trillion tax cut, President Trump threw himself back into the discussion, suggesting that Republicans could reduce taxes even further by repealing the Affordable Care Act’s mandate that most people have health insurance.
In recent weeks, Mr. Trump has called for including the repeal of the individual mandate in the tax bill. Doing so would save more than $300 billion over a decade and would allow Republicans to boast that they took a step forward in dismantling a law that continues to haunt them.” (G)

President Donald Trump remains intent on undoing the Obamacare individual mandate one way or another.
Encouraged by Trump, a group of congressional conservatives want to add repeal of the mandate to the GOP’s overhaul of the tax code. But other Republicans fear the toxic politics of Obamacare could jeopardize the tax fight, and so far have kept repeal language out of both Senate and House versions of the tax package.
That means it could be left to Trump to act unilaterally to neutralize what polls consistently show to be the most unpopular part of the Affordable Care Act.
Most legal observers believe the administration has the necessary authority to interpret the law and substantially weaken enforcement of the tax penalty levied on most Americans who fail to obtain coverage. The downside is that unraveling the mandate might ultimately make it harder for Republicans to follow through on their long-standing promise to repeal and replace Obamacare.
The White House has drafted an executive order to scrap the individual mandate, but is waiting to see if Congress opts to go first, multiple media outlets reported this week. House Ways and Means member Jim Renacci (R-Ohio) worked behind the scenes to add a repeal provision to tax legislation moving to the House floor, according to a source close to the talks.
The White House denies that any executive action is imminent.
“We are always looking for ways to provide relief from Obamacare,” said a spokesman in an email. “The longstanding issues with the mandate would be best resolved legislatively.” (H)

“After cutting funds for nonprofit groups that help people obtain health insurance under the Affordable Care Act, the Trump administration is encouraging the use of insurance agents and brokers who are often paid by insurers when they help people sign up.
The administration said in a recent bulletin that it was “increasing partnerships” with insurance agents and viewed them as “important stakeholders” in the federal marketplace, where consumers are now shopping for insurance. But some health policy experts warned that a shift from nonprofit groups, which are supposed to provide impartial information, to brokers and agents, who may receive commissions for the plans they recommend, carries risks for consumers.
“Insurance agents can educate consumers about the marketplace, and that is a good thing,” said Sabrina Corlette, a research professor at Georgetown University’s Health Policy Institute. “But I worry that they work on a commission and therefore have a financial incentive to steer consumers to particular products, which may or may not be in the consumer’s best interest.”” (I)

“Buried in almost every version of the Republican health care legislation this year was a little provision that would have enabled states to make a major change to their Medicaid programs, by requiring people to work if they’re going to get coverage. When those bills died, it appeared that Medicaid work requirements died with them.
But this week, Seema Verma, the head of the Centers for Medicaid & Medicare Services and a longtime supporter of work requirements, sent a strong message that work requirements are back on the table. In a speech to the country’s Medicaid directors, Verma lambasted the Obama administration’s approach to Medicaid, calling it a “tragic example of the soft bigotry of low expectations,” and argued that requiring Medicaid beneficiaries to work would improve the program.
The speech doesn’t result in any immediate policy changes, but CMS is reviewing at least seven waiver proposals from GOP-led states that would impose work requirements on their Medicaid populations. The details around each waiver vary and it’s unclear whether Verma, who helped design a work requirement policy in Indiana that was rejected by the Obama administration, will ask states to tweak their submissions or when she will approve the first waiver. But her speech this week was a clear sign that big changes are coming to Medicaid — even without any help from Congress.” (J)

“For years, red states have effectively been subsidizing part of health insurance for blue states.
By declining to expand their Medicaid programs as part of the Affordable Care Act, many of those states have passed up tens of billions of federal dollars they could have used to offer health coverage to more poor residents. That means that taxpayers in Texas are helping to fund treatment for patients with opioid addiction in Vermont, while Texans with opioid problems may have no such option.
If they did, they could collect billions of federal dollars to help them cover more low-income residents.
Now new estimates prepared by the consulting firm Avalere Health for The Upshot give a sense of just how much states are giving up. Texas could collect around $42 billion in Medicaid over a decade if it opted in, according to the Avalere analysis. Tennessee could pull in around 5 percent of its state budget next year. Altogether, Avalere estimates that the 18 states that have still not expanded Medicaid could give up more than $180 billion over the next 10 years.” (K)

(A) Senate Plans to End Obamacare Mandate in Revised Tax Proposal, by THOMAS KAPLAN and JIM TANKERSLEY, https://www.nytimes.com/2017/11/14/us/politics/tax-plan-senate-obamacare-individual-mandate-trump.html?_r=0
(B) Obamacare’s Insurance Mandate Is Unpopular. So Why Not Just Get Rid of It?, by Margot Sanger-Katz, https://www.nytimes.com/2017/11/14/upshot/obamacares-insurance-mandate-is-unpopular-so-why-not-just-get-rid-of-it.html
(C) Trump nominates former drug company executive Alex Azar as next Health and Human Services secretary, by Dan Mangan, https://www.cnbc.com/2017/11/13/trump-nominates-alex-azar-as-next-hhs-secretary.html
(D) Pence’s health care power play, by By ADAM CANCRYN, https://www.politico.com/story/2017/11/13/pence-health-care-azar-244859
(E) Who is Alex Azar? Former drugmaker CEO and HHS official nominated to head agency, by Maureen Groppe, https://www.usatoday.com/story/news/2017/11/13/former-pharmaceutical-ceo-nominated-trump-head-department-health-and-human-services/858240001/
(F) The Health 202: The Trump appointee you’ve never heard of who’s reshaping health policy, by Paige Winfield Cunningham, https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2017/11/13/the-health-202-the-trump-appointee-you-ve-never-heard-of-who-s-reshaping-health-policy/5a05e5fa30fb045a2e002f8e/?utm_term=.eabfd0d7cd19
(G) Trump Again Wades Into Tax Debate, Suggesting Repeal of Obamacare Mandate, by ALAN RAPPEPORT and THOMAS KAPLAN, https://www.nytimes.com/2017/11/13/us/politics/trump-taxes-obamacare-individual-mandate.html?_r=0
(H) Trump may use executive power to weaken Obamacare’s individual mandate, by Paul Demko, https://www.politico.com/story/2017/11/10/trump-executive-power-obamacare-mandate-244782
(I) Trump Administration Guiding Health Shoppers to Agents Paid by Insurers, by ROBERT PEAR, https://www.nytimes.com/2017/11/11/us/politics/obamacare-health-insurance-marketplace-agents.html?_r=0
(J) 5 things Trump did this week while you weren’t looking, by DANNY VINIK, https://www.politico.com/agenda/story/2017/11/10/trump-policy-immigration-cuba-regulation-000582
(K) What Red States Are Passing Up as Blue States Get Billions, by MARGOT SANGER-KATZ and KEVIN QUEALY, https://www.nytimes.com/2017/11/13/upshot/what-red-states-are-passing-up-as-blue-states-get-billions.html

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