“Mr. Trump declared that his plan was now to “let Obamacare fail,” and suggested that Democrats would then seek out Republicans to work together on a bill to bury the Affordable Care Act. If he is determined to make good on that pledge, he has plenty of levers to pull, from declining to reimburse insurance companies for reducing low-income customers’ out-of-pocket costs to failing to enforce the mandate that most Americans have health coverage.
“It’ll be a lot easier,” Mr. Trump said at the White House, adding: “We’re not going to own it. I’m not going to own it. I can tell you the Republicans are not going to own it. We’ll let Obamacare fail, and then the Democrats are going to come to us.” “ (A)

“It is true that the markets are looking shaky in some places. There are regions of Nevada, Indiana and Ohio where no insurers wish to offer Obamacare plans next year. In many other locations, competition has declined. And it appears that insurers are requesting hefty rate increases in many of the places they will stay.
But the Trump administration, rather than working to solve those problems, has mostly described them as failures of the previous administration. The White House has declined to say whether it will continue to pay certain subsidies to plans for very low-income Americans, subsidies seen as vital to the financial health of the exchange business. And it has suggested that it might decline to enforce the law’s individual mandate. Both of those actions will tend to raise prices, discourage insurer participation and make Obamacare shakier than it would be otherwise. (B)

There is “…..significant instability caused by the lack of commitment from the administration (or Congress) to fund the ACA’s cost-sharing reduction subsidies or to enforce the individual mandate.
The ACA requires insurers to cover cost-sharing subsidies to help low-income exchange enrollees pay out-of-pocket costs like deductibles and copays, with the understanding that they will be reimbursed by the federal government. However, these payments to insurers are currently subject to legal challenges, and the administration has been unclear regarding whether it intends to continue to fund them (or ask Congress to do so legislatively). Similarly, it is highly unclear whether the administration plans to enforce the law’s individual mandate, or whether they will actively support the marketing of policies during open enrollment.” (C)

“…. market stability is defined as the creation of a marketplace that both insurers and insureds will find worth participating in. This involves striking a balance between protecting insurers from the risks inherent in a market that is in transition and ensuring that consumers have access to meaningful and affordable coverage.”….” The CBO defines stability as “having insurers participating in most areas of the country and on the likelihood of premiums’ not rising in an unsustainable spiral.” (D)
To see a robust discussion on the five key considerations in achieving individual health insurance market stability, highlight and click on http://www.milliman.com/insight/2017/Five-key-ways-to-help-stabilize-the-inividual-and-small-group-health-insurance-markets-in-2018/?lng=1041

“The Senate health care bill appears to be dead—done in by the Republican Party’s inability to agree on a basic philosophical question: Should healthy Americans have to subsidize the sick?….The Republicans never resolved the fundamental question of how they should assist the sick. Instead, they tried to muddle past the issue with a series of murky compromises. Now, their entire seven-year quest to repeal Obamacare seems to have sunk under the weight of that indecision.” (E)

U.S. Sen. Lamar Alexander (R-Tenn.) today released the following statement:
“My main concern is doing all I can to help the 350,000 Tennesseans and 18 million Americans in the individual market who may literally have no options to purchase health insurance in 2018 and 2019. However the votes come out on the health care bill, the Senate health committee has a responsibility during the next few weeks to hold hearings to continue exploring how to stabilize the individual market. I will consult with Senate leadership and then I will set those hearings after the Senate votes on the health care bill.” (F)

(A) ‘Let Obamacare Fail,’ Trump Says as G.O.P. Health Bill Collapses, by Thomas Kaplan, https://www.nytimes.com/2017/07/18/us/politics/republicans-obamacare-repeal-now-replace-later.html
(B) Obamacare’s Future Now Depends on an Unhappy White House, by Margot Sanger-Katz, https://www.nytimes.com/2017/07/18/upshot/obamacares-future-now-depends-on-an-unhappy-white-house.html?smprod=nytcore-ipad&smid=nytcore-ipad-share
(C) To promote stability in health insurance exchanges, end the uncertainty around cost-sharing and other rules, by Erin Trish, Loren Adler, and Paul B. Ginsburg, https://www.brookings.edu/blog/up-front/2017/04/20/to-promote-stability-in-health-insurance-exchanges-end-the-uncertainty-around-cost-sharing-and-other-rules/
(D) Five key ways to help stabilize the individual and small group health insurance markets in 2018, by Lindsy Kotecki and Hans K. Leida,, http://www.milliman.com/insight/2017/Five-key-ways-to-help-stabilize-the-individual-and-small-group-health-insurance-markets-in-2018/?lng=1041
(E) The Controversy That Finally Killed the Senate Health Care Bill, by Jordan Weissmann, http://www.slate.com/blogs/moneybox/2017/07/18/the_controversy_that_finally_killed_the_senate_health_care_bill.html
(F) Chairman Alexander Statement on Senate’s Work on Individual Health Insurance Market, https://www.help.senate.gov/chair/newsroom/press/chairman-alexander-statement-on-senates-work-on-individual-health-insurance-market-

“President Donald Trump said Tuesday he would let Obamacare “fail” in the aftermath of his party’s botched efforts to repeal and replace the Affordable Care Act. “I think we’re probably in that position where we’ll let Obamacare fail,” Trump said at the White House. “We’re not going to own it. I’m not going to own it. I can tell you, the Republicans are not going to own it.” Once Obamacare collapses, Trump said Democrats would join Republicans so Congress would be able to “come up with new plan, really good for people.”” (A)

“Trump’s response also vacillated wildly in the hours after the BCRA’s collapse. First, he advocated for immediate repeal with no set replacement. Then, he suggested early Tuesday that Republicans should leave Obamacare in place and come back around when it “fails.”” (B)

After Real Now/ Replace Later died last night…“U.S. Senate Republican leader Mitch McConnell had set a vote on a straight repeal of Obamacare after it became clear he did not have the votes to overhaul the healthcare law, but the new approach unraveled within hours.
Republican Senators Shelley Moore Capito of West Virginia, Susan Collins of Maine and LisaMurkowski of Alaska quickly announced they would not back repeal, dooming the fledgling effort. With Democrats united in opposition, Republicans can only afford to lose two votes to pass the measure in the Senate, where they have a slim 52-48 majority.”
“I do not think that it’s going to be constructive to repeal a law that at this point is so interwoven within our healthcare system and then hope that over the next two years we will come up with some kind of replacement,” Collins told reporters.” (C)

“An independent analysis of such an approach by the nonpartisan Congressional Budget Office earlier this year concluded that it would lead to 32 million more uninsured Americans over the next decade.
That is some 10 million more than predicted under the Senate repeal-and-replace plan that was scuttled Monday night, which was projected to increase the number of uninsured by 22 million by 2026.
At the same time, repealing major planks of Obamacare without a replacement would cause insurance premiums to jump by 20% to 25% next year for Americans who rely on insurance marketplaces, budget analysts concluded.
And premiums would double by 2026, according to the report.” (D)

“Despite not having the votes for passage, McConnell announced Tuesday night on the Senate floor that Republicans would hold a procedural vote on the health care bill “early next week.”…..
“I think what has to happen is the Republicans have to admit that some of the things in the ACA, we actually liked, and the Democrats have to admit that some of the things they voted for in the ACA are broken and need to be fixed,” Senator Murkowski told reporters……
After the chaos of Tuesday, Sen. Lamar Alexander, the Senate’s health committee chairman, acknowledged that it was time for Republicans to open up the process. He announced that his committee would begin holding hearings on how to stabilize the health care market — an area that enjoys potential bipartisan cooperation.” (E)

The collapse of the Senate Republican health bill — and the failing struggle to find yet another alternative — highlighted a harsh reality for Senate Republicans: While Republican senators freely assailed the health law while Mr. Obama occupied the White House, they have so far not been able to come up with a workable plan to unwind it that would keep both moderate Republicans and conservatives on board. (F)

(A) Trump: ‘Let Obamacare Fail…I’m Not Going to Own It’, by Kristen Welker, Adam Edelman and Ali Vitali, http://www.nbcnews.com/politics/donald-trump/trump-lays-blame-health-care-bill-failure-n784006
(B) An ‘unmitigated disaster for Trump’: President’s agenda in shambles after healthcare collapse, by Bob Bryan, http://www.businessinsider.com/senate-health-care-bill-vote-trump-agenda-2017-7
(C) Republican push to overhaul or repeal healthcare law collapses in Senate, https://www.aol.com/article/news/2017/07/18/republican-senator-lisa-murkowski-wont-back-repeal-only-health-bill/23035980/
(D) McConnell’s latest Obamacare repeal plan also collapsing amid more Republican defections, by Noam N. Levey and Lisa Mascaro, http://www.latimes.com/politics/washington/la-na-essential-washington-updates-senate-republicans-new-plan-to-repeal-1500389717-htmlstory.html
(E) Mitch McConnell refuses to pull the plug on stalled Obamacare repeal plan, by MJ Lee and Lauren Fox, http://www.cnn.com/2017/07/18/politics/mcconell-repreal-and-replace-obamacare-not-successful/index.html
(F) ‘Plan C’ on Obamacare, Repeal Now and Replace Later, Has Collapsed by Thomas Kaplan, https://www.nytimes.com/2017/07/18/us/politics/republicans-obamacare-repeal-now-replace-later.html

“Senate Majority Leader Mitch McConnell was handed devastating news Monday evening just hours after the Senate was gaveled back into session: Two more defections on his health care bill.
The dramatic and simultaneous announcement from Sens. Jerry Moran of Kansas and Mike Lee of Utah means McConnell officially does not have the votes to even begin debate on his legislation to overhaul the Affordable Care Act — and that the Republican Party’s years-long quest to kill former President Barack Obama’s legacy accomplishment is, for the time being, halted without a path forward….
“We should not put our stamp of approval on bad policy. Furthermore, if we leave the federal government in control of everyday healthcare decisions, it is more likely that our healthcare system will devolve into a single-payer system, which would require a massive federal spending increase,” Moran said in a statement.” (A)

Senate minority leader New York Sen. Charles Schumer said in a statement that the “second failure of Trumpcare is proof positive” that the bill is “unworkable.”
“Rather than repeating the same failed, partisan process yet again, Republicans should start from scratch and work with Democrats on a bill that lowers premiums, provides long term stability to the markets and improves our health care system,” Schumer said. (B)

“With four solid votes against the bill, Republican leaders were faced with two options: go back and try to rewrite the bill in a way that could secure 50 Republican votes, a seeming impossibility at this point, or do as Senator Mitch McConnell, the Republican leader, had promised and team with Democrats to draft a narrower, bipartisan measure to fix the flaws in the Affordable Care Act that both parties acknowledge.”(C)

(A) Latest health care bill collapses following Moran, Lee defections, by MJ Lee, Phil Mattingly and Ted Barrett, http://www.cnn.com/2017/07/17/politics/health-care-motion-to-proceed-jerry-moran-mike-lee/index.html
(B) More GOP Senators Say No, Killing Chances For Republican Health Care Bill, by Scott Neuman, http://www.npr.org/sections/thetwo-way/2017/07/17/537803874/gop-senators-come-out-against-republican-healthcare-bill-ensuring-it-cant-pass
(C) Health Care Overhaul Collapses as Two More Republican Senators Defect, by Thomas Kaplan and Robert Pear, https://www.nytimes.com/2017/07/17/us/politics/health-care-overhaul-collapses-as-two-republican-senators-defect.html

Last week he also said:
“Introduce a bill,” McCain said. “Bring it to the floor. Vote on it. That’s the normal process, and if you shut out the adversary or the opposite party, you’re going to end up the same way Obamacare did when they rammed it through with 60 votes. Only guess what? We don’t have 60 votes.” (B)

“Senate Majority Leader Mitch McConnell announced Saturday that the Senate will delay consideration of the Republican health care bill while Sen. John McCain recovers from surgery for a blood clot.
McConnell tweeted that the Senate will work on other legislative issues and nominations next week and “will defer consideration of the Better Care Act” while McCain is recovering. McCain’s absence would have imperiled the bill, which needs the support of 50 of 52 GOP senators to advance.
Two Republican senators — Susan Collins of Maine and Rand Paul of Kentucky — have already said they will not support a motion to proceed to floor debate on the legislation.”
With Senator John McCain’s absence, Republicans would have only 49 votes to move ahead with the legislation; all Democrats and the two independent senators oppose it. (C)

What is JUNK INSURANCE?
“As Senate Republican leaders struggle to secure enough votes to repeal and replace the health law, the centerpiece of their effort to win conservative support is a provision that would allow insurers to sell such bare-bones plans again. The new version of the bill released on Thursday incorporates an idea from Senator Ted Cruz of Texas that would permit insurers to market all types of plans as long as they offer ones that comply with Affordable Care Act standards. The measure would also allow companies to take into account people’s health status in determining whether to insure them and at what price.
State insurance regulators say the proposal harks back to the days when insurance companies, even household names like Aetna and Blue Cross, sold policies so skimpy they could hardly be called coverage at all. Derided as “junk insurance,” the plans had very low premiums but often came with five-figure deductibles. Many failed to pay for medical care that is now deemed essential…
The Affordable Care Act drastically changed the health insurance landscape by requiring insurers to offer a set of comprehensive benefits — including hospitalization, doctor visits, prescription drugs, maternity care and mental health and substance abuse treatment — in order to formally qualify as insurance. “The new bill opens the door to junk insurance,” said Dave Jones, the California insurance commissioner.” (D)

WILL SENATOR McCAIN “WALK THE WALK” OR LIKE MOST SENATORS OF BOTH PARTIES JUST “TALK THE TALK?”

(A) McCain: Senate healthcare deal could be reached by Friday ‘if pigs fly’, by Mallory Shelbourne, http://thehill.com/homenews/senate/339934-mccain-senate-healthcare-deal-could-be-reached-by-friday-if-pigs-fly
(B) McCain: GOP health care bill ‘probably’ will die, by Eli Watkins, http://www.cnn.com/2017/07/09/politics/john-mccain-health-care/index.html
(C) McConnell delays health care vote while McCain recovers from surgery, by Phil Mattingly, Manu Raju and Steve Almasy, http://www.cnn.com/2017/07/15/politics/john-mccain-blood-clot/index.html
(D) In Clash Over Health Bill, a Growing Fear of ‘Junk Insurance’, by Reed Abelson, https://www.nytimes.com/2017/07/15/health/senate-health-care-obamacare.html

Republic Party Talking Points (A)
The Better Care Reconciliation Act is only one step in a three step process to replace the Affordable Care Act and lower healthcare costs. Step two includes administrative actions, by the Department of Health and Human Services Secretary, that will make regulatory reforms to the health insurance market. Step three includes additional healthcare legislation that cannot be done through the reconciliation process.
FACTS ABOUT THE REVISED BETTER CARE RECONCILIATION ACT:
Lowers health insurance premiums by 30% by 2020, compared to Affordable Care Act projections.
Requires continued coverage for people with preexisting conditions.
Allows dependents to stay on their parents health policies until age 26.
Dedicates $132 billion, over 8 years, to encourage states to assist low-income individuals to purchase health insurance.
Impacts Members of Congress healthcare just like all Americans.
Allows insurers to offer cheaper plans with less coverage options.
Does not make any changes from current law to annual lifetime coverage limits.
Does not cut Medicaid. Funding for Medicaid would continue to grow, yet not at the steep, beyond-inflation growth that is projected over the next 10 years. In fact, under the BCRA, spending on Medicaid in 2026 will increase to $466 billion, a 26 percent increase from now.
Provides state Governors with more flexibility in how their Medicaid system provides healthcare to those who are eligible.
Provides assistance for low-income Americans by offering health insurance subsidy assistance for Americans in the 0% to 350% federal poverty level range. This would also benefit the approximately 82,000 Oklahomans in the “coverage gap.” This tax subsidy will expand healthcare access and choice for low-income Americans, because they can transition from Medicaid to private insurance, with the help of tax subsides.
Eliminates the individual and employer mandates penalties.
Makes no changes to Medicare (which is the primary source of health coverage for Americans 65 and older).
Protects against an “age tax” by limiting what older, middle-income Americans pay toward the purchase of health insurance, to ensure they have access to a plan that fits within their financial means.
Helps rural hopsitals by restoring Affordable Care Act cuts to Medicaid Disproportionate Share Hospitals (DSH), which helps non-expansion states pay hospitals an enhanced Medicaid payment to care for its safety net population.
Allows people to use their pre-tax Health Savings Accounts (HSAs) to pay for their health insurance premiums.
Creates a Medicaid special exemption for disabled children from the per capita caps, which guarantees children with medically complex disabilities will continue to be covered through Medicaid.
Will not include any changes from current law to the net investment income tax, the additional Medicare Health Insurance (HI) Tax, or the remuneration tax on executive compensation for certain health insurance executives.

Democratic Party response (B)
Washington—Senator Dianne Feinstein (D-Calif.) today released the following statement in reaction to the Senate Republican health care bill:
“Senate Republicans spent the past two weeks putting lipstick on a pig. In all the ways that matter, the health care bill unveiled today is the same atrocious bill they couldn’t pass two weeks ago.
“The bill would still take coverage from tens of millions. It would still gut Medicaid. It would still increase premiums, particularly for older Americans. It would still undermine protections for pre-existing conditions.
“Once again, this bill was written behind closed doors. There will be no hearings. There will be no markups. There will be no opportunity for senators to amend the bill or understand the views of the millions who would be affected by it.
“Democrats will do all we can to ensure the American people understand that this bad bill is no better than the previous bad bills.”

FamiliesUSA (C)
Just as with earlier versions, the latest iteration of the Senate’s Affordable Care Act repeal bill would devastate insurance coverage, gut the Medicaid program, and dramatically increase deductibles and out of pocket costs.
The newest repeal bill:
leaves in place enormous cuts to Medicaid and ends the Medicaid expansion;
ensures that millions of low-income workers will lose health coverage and that those left on Medicaid will be enrolled in a hollowed out program with funding reduced by 35% over time;
continues to allow states to eliminate the essential health benefits and minimum coverage requirements that are core protections for people with pre-existing conditions and goes a lot further in this damaging direction, imposing a new structure—thought up by Senator Ted Cruz—that further erodes pre-existing conditions protections;
continues to cut financial assistance for private coverage and eliminates all assistance with out-of-pocket costs like deductibles;
increases deductibles for working lower- and middle-income families across all ages by an average of close to $5,000;
still increases premiums for older people by hundreds to thousands of dollars on top of these new higher deductibles;
still institutes an age tax on premiums, allowing insurers to charge older people five times the premium of younger people;
still provides billions of dollars in tax cuts to the wealthy and corporations.
So what has changed?
Fewer protections for pre-ex
Shifts Medicaid funds into poorly defined block grants
A small substance abuse grant fund as a token offset to much larger Medicaid cuts
Lessens tax cuts but still benefits corporations and the wealthy
These changes largely make the profound problems in previous versions of the Senate bill worse. They will formally divide the market for individual health insurance into plans for people with pre-existing conditions and for healthier people. They offset huge cuts to Medicaid and the regulated individual health insurance market with small expansions in Medicaid block grants and substance use grants and a stabilization fund that goes direct to insurance companies.

(A) Senator Lankford Statement on Revised Senate Healthcare Bill, https://www.lankford.senate.gov/news/press-releases/senator-lankford-statement-on-revised-senate-healthcare-bill
(B) Feinstein Statement on Senate Health Care Bill, https://www.feinstein.senate.gov/public/index.cfm/press-releases?ID=E83D14CD-9BA0-4B97-B0F0-9C5EAE30F1C2
(C) Latest Version of Senate Health Care Bill Fundamentally the Same as Previous Versions, http://familiesusa.org/blog/2017/07/latest-version-senate-health-care-bill-fundamentally-same-previous-versions

“Overall, the new version of the bill made broad concessions to conservative Republicans who had maintained that the initial draft left too much of the Affordable Care Act in place. Mr. McConnell then backfilled the bill with money intended to placate moderates. That jury-rigging of the bill left neither side completely satisfied.” (A)

“The new bill includes major changes to the original. One of the most significant was the inclusion of an amendment by Texas Sen. Ted Cruz, which would allow insurers offering Obamacare plans to also offer cheaper, bare-bones policies. The amendment was included in an effort to earn more conservative support, but could also drive away some moderates who fear the amendment could drive up premiums for those with pre-existing conditions.
It also contains significant new funding for opioid treatment and money for states meant to lower premiums for high-cost enrollees. But it would keep two Obamacare-era taxes on the wealthy and maintains significant cuts to Medicaid, meaning 15 million fewer people could insured by the program by 2026.” (B)

“The Congressional Budget Office projected that the previous iteration would result in 22 million more uninsured in a decade. “Looking at the revised Senate health bill, it’s hard to see how it could meaningfully alter CBO’s projection of how the uninsured will grow,” the Kaiser Family Foundation’s Larry Levitt noted. “The revised Senate bill reinstates taxes on wealthy people, but it mostly does not spend that money on health care for low-income people.”” (C)

“The home state of a key undecided senator could receive hundreds of millions of dollars under an updated Senate GOP bill to repeal ObamaCare. Lisa Murkowski (R-Alaska) has withheld her support for the Senate’s Better Care Reconciliation Act, citing concerns over Medicaid cuts, Planned Parenthood funding and insurance affordability.
But a new provision could funnel more than $1 billion to her state over the next decade to help reduce the cost of insurance premiums. Under a formula in the revised Senate bill, only Alaska would qualify for additional money from the legislation’s $182 billion stability fund. The legislation would direct the money to states with disproportionately higher premiums. Under the bill, states with premiums that are at least 75 percent of the national average would qualify to keep one percent of the legislation’s long-term insurance stability fund. Alaska is the only state with premiums that high.” (D)

To see a great chart on Who’s In, Who’s Left Out With The Latest Senate Health Care Bill, highlight and click on http://www.npr.org/sections/health-shots/2017/07/13/537037194/whos-in-whos-left-out-with-the-latest-senate-health-care-bill (E)

“At its core, however, the revised version of the Better Care Reconciliation Act ― which McConnell pulled two weeks ago because too few Republican senators planned to vote for it ― remains a vehicle for massive cuts to Medicaid, less financial assistance for people who buy private health insurance, and the return of skimpy junk insurance policies and discrimination against people with pre-existing conditions. Taxes on the rich would remain, but health care companies would enjoy a major tax cut.” (F)

(A) Senate Republicans Unveil New Health Bill but Divisions Remain, by Robert Pear and Thomas Kaplanjuly, https://www.nytimes.com/2017/07/13/us/politics/senate-republican-health-care-bill.html
(B) New GOP health care bill could allow cheaper plans with fewer benefits, by Lauren Fox, Tami Luhby, MJ Lee and Ted Barrett, http://www.cnn.com/2017/07/13/politics/senate-health-care-bill-ted-cruz-amendment/index.html
(C) The new Senate health-care bill may be worse than the old one, https://www.washingtonpost.com/opinions/the-new-senate-health-care-bill-may-be-worse-than-the-old-one/2017/07/13/9aaffc18-680e-11e7-8eb5-cbccc2e7bfbf_story.html
(D) The home state of a key undecided senator could receive hundreds of millions of dollars under an updated Senate GOP bill to repeal ObamaCare, by Nathaniel Weixel, http://thehill.com/author/nathaniel-weixel
(E) Who’s In, Who’s Left Out With The Latest Senate Health Care Bill, by Gisele Grayson, http://www.npr.org/sections/health-shots/2017/07/13/537037194/whos-in-whos-left-out-with-the-latest-senate-health-care-bill
(F) The New Senate Health Care Bill Is Still An Assault On The Safety Net, by Jeffrey Young, http://www.huffingtonpost.com/entry/new-senate-health-care-bill-is-still-an-assault-on-the-safety-net_us_596791a5e4b0a0c6f1e69c3c