..congressional Republicans aim to reduce spending on federal health care programs to reduce America’s deficit

“We’re going to have to get back next year at entitlement reform, which is how you tackle the debt and the deficit,” Ryan said during an appearance on Ross Kaminsky’s talk radio show. “… Frankly, it’s the health care entitlements that are the big drivers of our debt, so we spend more time on the health care entitlements — because that’s really where the problem lies, fiscally speaking.”…
Ryan’s remarks add to the growing signs that top Republicans aim to cut government spending next year. Republicans are close to passing a tax bill nonpartisan analysts say would increase the deficit by at least $1 trillion over a decade. Trump recently called on Congress to move to cut welfare spending after the tax bill, and Senate Republicans have cited the need to reduce the national deficit while growing the economy.” (A)

“Healthcare lobbyists are scrambling to win changes in congressional Republican tax legislation, as Senate and House GOP leaders race to merge their separate bills into something both chambers can pass on a party-line vote this month.
But provider, insurer and patient advocacy groups doubt they can convince Republicans to remove or soften the provisions they find most objectionable. They say GOP leaders are moving too fast and providing too little opportunity for healthcare stakeholders to provide input….
Some lobbyists hold out a faint hope that the Republicans’ tax cut effort could collapse as a result of intra-party differences, as did their drive to repeal and replace the Affordable Care Act.
One possibility is that Maine Sen. Susan Collins flips and votes no on the tax cut bill emerging from the conference committee if congressional Republicans fail to pass two bipartisan bills she favors to stabilize the individual insurance market….
Collins conceivably could be joined by Alaska Sen. Lisa Murkowski, who also said she wants to see the market stabilization bills passed. If Tennessee Sen. Bob Corker, who voted no on the tax cut bill over deficit concerns, remains opposed, those three GOP senators could sink the tax bill. “We’d all like to see Collins pull her vote,” Hobson said. “It was always clear that the deal she cut with McConnell won’t fly on the House side.”” (“It appears virtually certain that repeal of the law’s individual mandate to buy coverage will be included in a final tax bill. Two of the moderate senators most likely to defect over that issue — Collins and Lisa Murkowski of Alaska — are okay with getting rid of the mandate, arguing it has been less effective than expected and its associated penalty is paid chiefly by lower-income Americans.
The question is whether Republicans will also manage to pass the two bipartisan measures essentially infusing cash into marketplace plans — a move that analysts say will help insurers lower premiums, which have been spiking across the country.” (B)

“A measure from Alexander and Sen. Patty Murray (D-Wash.) would fund $7 billion in extra cost-sharing discounts; another one from Collins and Sen. Bill Nelson (D-Fla.) would provide $4.5 billion in reinsurance funding. If either one passes, it probably would be as part of a big spending measure.” (C)

“So how’s that working out for you, Senator Collins?
The latest bit of bad news for Collins comes from Avalere Health. According to an analysis the healthcare consulting company released this morning, the reforms sought by Collins, while helpful, are possibly “overshadowed” when the Senate tax bill’s repeal of the individual mandate is taken into account.
The basic problem is that according to the Congressional Budget Office, mandate repeal will cause premiums to spike. The two pieces of legislation that Collins is supporting would try to make up for this. One bill would give insurers $4.5 billion over the next two years to help compensate for the costs of covering sick – read expensive – patients, something known as reinsurance. The other bill would restore payments to insurers — which Trump had stopped — and which would cover the cost of insuring low income people, otherwise known as cost-sharing reductions, or CSRs.
Together, they are supposed to keep down premiums. Caroline Pearson, a senior vice president at Avalere, told The Hill that their study concludes that “From a premium point of view, we do think reinsurance and CSRs probably covers the mandate.”
But this remains unclear. Topher Spiro, a health policy analyst at the liberal Center for American Progress, points out that the analysis actually doesn’t support that conclusion, once you take account of the fact that Trump has already halted the CSRs; restoring them will merely return us to the previous status quo.
What’s more, a number of healthcare wonks recently told Vox that the second of these two bills will not do nearly enough to fix the spiking premium problem.
And finally, the actions sought by Collins only cover a two-year period, and Avalere’s own experts conclude that once they expire, they would do little to deal with spiking premiums. As Elizabeth Carpenter, a senior vice president at Avalere, put it: “Eliminating the requirement to purchase coverage would create additional uncertainty in the market. It is important not to overlook the negative impact of repealing the individual mandate on long-term market stability.” (D)

“Ed Kilgore, writing in New York magazine, said Collins “is an experienced, savvy legislator. She knew when she cut her deals with Trump and McConnell that they would be worthless if the House didn’t go along.”
“She could have demanded assurances from Ryan and conservative leaders, too — certainly she could have demanded the moon at the point where it appeared she might be the decisive vote in the tax bill.
“What this series of events shows is that Collins, like the other alleged ‘holdouts,’ really wanted to ‘get to yes,’ as we kept hearing last week. If that meant securing a promise written in vanishing ink, so be it,” Kilgore said.
Collins’ office released a copy of the agreement reached between McConnell and Collins. Both had signed it. On its face, the ink looks pretty permanent.
In any case, whether Collins got played will be clear within weeks as Congress moves to adopt both the tax bill and a budget measure that Collins expects to include the health care measures she wants.” (E)

“Ms. Collins has released a copy of her agreement with Mr. McConnell in which he pledged to support passage of the two measures before the end of the year. His signature was displayed prominently at the top of the first page. But the deal has landed with a thud in the House, where Republicans appear loath to support legislation that they view as propping up a health law that they have pledged to repeal.
“Our members wince at voting to sustain a system that none of them supported,” said Representative Tom Cole, Republican of Oklahoma.
The Senate could attach the Alexander-Murray legislation to a government funding measure, hoping that Republicans in the House would be willing to swallow it as part of a measure to avoid a government shutdown. But Mr. Cole said House Republicans would be “very offended” at such an approach.
“I don’t think we’re in the mood to be blackmailed by anybody,” he said.
Mr. Brat, a member of the conservative Freedom Caucus, assailed the deal with Ms. Collins as an example of horse trading that is characteristic of the Washington swamp that he said voters had repudiated.
Likewise, Representative Mark Walker of North Carolina, the chairman of the conservative Republican Study Committee, said of the Alexander-Murray bill, “There’s no appetite for that over here.”
Ms. Collins said on Wednesday that she believed the House would “take a serious look” at the two bills intended to hold down insurance premiums and that Mr. Trump, in several recent meetings, had assured her that he also supported those bills.
“I don’t think this effort is over by any means,” Ms. Collins said.” (F)

“…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….
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.”…
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.”” (G)

“A reinsurance program funded with $10 billion or even $15 billion in annual spending could actually offset the price hikes expected to result from individual mandate repeal. But that, of course, costs more money. And again, it doesn’t address what happens after 2020 at all.
This is what experts predicted about the Collins bill. “The Collins-Nelson bill would help mitigate premium increases resulting from repeal of the individual mandate, but it would fall short of completely offsetting the hikes,” Larry Levitt at the Kaiser Family Foundation told Dylan last week.
And at the end of the day, a lot of this debate may be moot. The Collins plan needs 60 votes to move through the Senate (unlike the tax bill, which is being run through the reconciliation process and thus only requires 50 votes). Whether Democrats would want to work with Republicans to pass a bill like this — whether more conservative senators would even get on board — is a big open question.
My takeaway from the Avalere analysis is this: Repealing the individual mandate will cause uncertainty and confusion in the individual market. That much is certain. The Collins plan is a Band-Aid on a much larger problem caused by the Senate bill — one that it just can’t fix.” (H)

“After taking a beating for three years, health plans jacked up their rates for 2017, with the average premium on the most popular products rising more than 20 percent. That created sticker shock for many Obamacare customers while putting many insurers on pace to record profits this year for the first time, according to a POLITICO analysis of 31 regional Blue Cross Blue Shield plans, many of which dominate Obamacare markets in their states.
But the turnaround comes just as Republican efforts to dismantle the health care law are creating new threats to the viability of the marketplaces. That leaves the plans in a bewildering situation, trying to improve their margins while the GOP declares Obamacare a failure and mounts another push to dismantle the system, starting with rolling back the health care law’s individual mandate.
“The political narrative is over a market in crisis, and that’s just not how the market actually looks right now,” said Larry Levitt, senior vice president for special initiatives at the Kaiser Family Foundation, a nonpartisan research group. “At this moment, the individual insurance market looks quite stable and most insurers have achieved profitability.” (I)

“The two core pieces of Obamacare are the subsidies that help middle-class families afford private insurance and the expansion of Medicaid for working-class families. The tax bill doesn’t get rid of either. Instead, it will likely repeal the individual mandate — the requirement that people buy health insurance. As a result, health-insurance markets will suffer some turmoil, and costs for some families will rise.
Most people who want health insurance will still be able to get it, though. And health care advocates can reduce the impact of the mandate’s repeal through public-information campaigns that encourage people to sign up. The elimination of the insurance subsidies and Medicaid expansion would be qualitatively worse.
Many big fights remain. The tax bill’s supporters have a clear vision, and they’ve been surprisingly up front about that vision. The first step is to cut taxes. The second is to cut government programs like Medicare, Social Security, Medicaid and much else.
But this tax bill itself doesn’t accomplish the second step (with the exception of some modest automatic cuts). Republicans will have to pass other bills to shrink programs that benefit the middle class. Democrats are already gearing up to have those debates, as they should be. A McClatchy news headline yesterday: “Dems warn GOP: We’re prepared for class war.” Debates over spending cuts are easier for Democrats to win than debates over tax policy.” (J)

“Sen. Susan Collins (R-Maine) said Thursday that she may change her vote on the final version of the GOP tax-reform bill if her proposed amendments are not included in its final version.
“I would. I’m going to look at what comes out of the conference committee meeting to reconcile the differences between the Senate and House Bill. So I won’t make a final decision until I see what that package is,” Collins told CBS WABI 5 when asked if she would consider changing her vote…
“There’s a real fear that the tax bill is going to trigger a 4 percent cut in Medicare,” Collins added. “I am absolutely certain that 4 percent cut in Medicare that I mentioned will not occur. I have it in writing from both the Speaker of the House Paul Ryan [R-Wis.] and also Sen. Mitch McConnell [R-Ky.].”
Collin expressed optimism that the final bill will adopt her amendments.” (K)

“For the moment, none of this appears to have shaken Collins’s support for the bill. But it has ensured that her second vote for the Trump tax cuts will be more politically painful than her first one. Beyond the collapse of her health-care “deal,” the Republican bill isn’t getting any less (historically) unpopular. And progressive activists in Maine are mobilizing in opposition.
If Collins were to lose her nerve — and Tennessee senator Bob Corker were to retain his opposition to the bill on deficit grounds — then McConnell would only have one vote to spare. Should one of the multiple elderly, Republican senators with ongoing medical problems fall ill — or, should Doug Jones win Alabama’s special Senate election next week — the Trump tax cuts could conceivably fall into jeopardy.” (L)

(A) Ryan says Republicans to target welfare, Medicare, Medicaid spending in 2018, by Jeff Stein, https://www.washingtonpost.com/news/wonk/wp/2017/12/01/gop-eyes-post-tax-cut-changes-to-welfare-medicare-and-social-security/?utm_term=.5b3ab0175186
(B) Healthcare lobbyists not optimistic on changing GOP tax bill, By Harris Meyer, http://www.modernhealthcare.com/article/20171206/NEWS/171209899
(C) The Health 202: Senate GOP intensifies push to send more cash to Obamacare marketplaces, By Paige Winfield Cunningham, https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2017/12/07/the-health-202-senate-gop-intensifies-push-to-send-more-cash-to-obamacare-marketplaces/5a28164030fb0469e883fa53/?utm_term=.228c5c6f8672
(D) Susan Collins is getting played. Will she really vote for the tax bill in the end?, by Helaine Olen, https://www.washingtonpost.com/blogs/plum-line/wp/2017/12/06/susan-collins-is-getting-played-will-she-really-vote-for-the-tax-bill-in-the-end/?utm_term=.cb71725eaf59
(E) Despite criticism, Susan Collins is confident that GOP leaders will stand by their word, by Steve Collins, http://www.sunjournal.com/despite-criticism-susan-collins-is-confident-that-gop-leaders-will-stand-by-their-word/
(F) Tax Bill Is Likely to Undo Health Insurance Mandate, Republicans Say, By ROBERT PEAR and THOMAS KAPLAN, https://www.nytimes.com/2017/12/06/us/politics/tax-bill-obamacare-mandate-collins.html?_r=0
(G) It’s looking like Trump’s Obamacare meddling could cause serious problems for the healthcare market, by Bob Bryan, http://www.businessinsider.com/trump-obamacare-enrollment-insurance-market-2017-12
(H) Sen. Collins’s health proposal isn’t going to save Obamacare, by Sarah Kliff, vox.com. Dec 6, 2017
(I) POLITICO survey: Insurers finally making money on Obamacare, by PAUL DEMKO, https://www.politico.com/story/2017/12/07/obamacare-profits-health-care-285258
(J) The Republic Will Survive the Tax Bill, by David Leonhardt, https://www.nytimes.com/2017/12/06/opinion/republican-tax-bill.html
(K) Collins considers changing vote on tax bill over amendments, by JOSH DELK, http://thehill.com/blogs/blog-briefing-room/363891-collins-considers-changing-vote-on-tax-bill-over-amendments
(L) Senate Republicans Made a $300 Billion Mistake in Their Tax Bill, by Eric Levitz, http://nymag.com/daily/intelligencer/2017/12/the-senate-gop-made-a-usd300-billion-mistake-in-their-tax-bill.html