“The official rules keeper in the Senate Friday tossed a bucket of cold water on the Senate Republican health bill by advising that major parts of the bill cannot be passed with a simple majority, but rather would require 60 votes. Republicans hold only 52 seats in the Senate.
Senate Parliamentarian Elizabeth MacDonough said that a super-majority is needed for the temporary defunding of Planned Parenthood, abortion coverage restrictions to health plans purchased with tax credits and the requirement that people with breaks in coverage wait six months before they can purchase new plans.
The Senate is using a budget process called “reconciliation” that allows Republicans to pass a bill with only 50 votes (and the potential tie to be broken by Vice President Mike Pence). But there are strict rules about what can and cannot be included, and those rules are enforced by the parliamentarian. Those rules can be waived, but that requires 60 votes, and all the chamber’s Democrats have vowed to fight every version of the bill to “repeal and replace” the Affordable Care Act, which is set for a possible vote next week.” (A)

“In a blow to the insurance industry, the parliamentarian has advised that two key market stabilization provisions in the bill would be against the rules. First, the legislation can’t appropriate the cost-sharing reduction subsidies insurers rely on to keep premiums and deductibles low; it can only repeal them.
Additionally, a “lockout” provision requiring consumers with a break in coverage to wait six months before buying insurance also violates the rules, according to the guidance.”
“The parliamentarian has also not yet ruled on a controversial amendment from Sen. Ted Cruz (R-Texas) that would allow insurers to sell plans that do not meet ObamaCare regulations. If that provision were struck, conservative support for the bill would be in doubt.”…
“The result is that the arcane rules of the Senate could end up making the bill harder for Senate Majority Leader Mitch McConnell (R-Ky.) to pass.” (B)

“In general, the parliamentarian has taken an already very difficult process for enacting health care legislation in the Senate and made it nearly impossible—unless Mitch McConnell is willing to blow up every Senate precedent without even knowing if it would be enough to persuade 50 senators from his own party. It will be a painful weekend for those whose dreams involve the repeal or replacement of Obamacare.” (C)

(A) Senate Parliamentarian Upends GOP Hopes For Health Bill, by Julie Rovner, http://khn.org/news/ruling-by-senate-parliamentarian-upends-gop-hopes-for-health-care-bill/
(B) Parliamentarian deals setback to GOP repeal bill, by Nathaniel Weixel, http://thehill.com/policy/healthcare/343234-parliamentarian-deals-setback-to-gop-healthcare-bill
(C) Senate Parliamentarian May Have Dealt the Last, No-Kidding-Final, Blow To Trumpcare, by Ed Kilgore, http://nymag.com/daily/intelligencer/2017/07/parliamentarian-deals-potentially-terminal-blow-to-trumpcare.html

As we head towards next week’s vote, you might take a look at an excellent New York Magazine analysis.
Here Is Where Things Stand With the Senate Health-Care Bill , by Ed Kilgore, highlight and click on http://nymag.com/daily/intelligencer/2017/07/where-things-stand-with-the-senate-health-care-bill.html

Excerpts:
“Getting Senate moderates to vote for a bill with a Medicaid per capita cap and the Cruz amendment is where the whole process has ground to a halt. But it seems the strategy is for McConnell to throw absolutely every nickel of funding at his disposal (somewhere in the neighborhood of $200 billion in “excess” deficit reduction, according to the latest Congressional Budget Office’s assessment of the revised BCRA) at the states to ease immediate coverage concerns caused by the rest of the bill.
But there is an existential threat to this scheme that could emerge as early as today, when the Senate parliamentarian informally lets senators know of her rulings as to whether various provisions of the pending bill (and various likely amendments) pass muster under budget rules requiring that all items are germane to federal spending and revenue levels. According to a handful of experts assembled by the Times, there is a decent chance the parliamentarian will deem the Cruz amendment unallowable. If so, that would leave McConnell with the unsavory choice of finding some way to regain conservative support for yet another revision of BCRA or, worse yet, overturning the parliamentarian’s ruling on the Senate floor. This latter contingency would, many fear, lead to a de facto abolition of the legislative filibuster, since a simple majority could at any time rule any provision germane to a budget bill, which cannot be filibustered.”

“A new official analysis released Wednesday finds that repealing much of Obamacare without a replacement law would increase the number of people without health insurance by 32 million people, double insurance premiums in the individual plan market and leave most of the United States without an insurer selling such plans by 2026.
The report comes as Republican leaders in the Senate, desperate to pass some kind of health-care law, have said that next week they might consider a possible Obamacare repeal bill that could eventually be amended to include a replacement.
The Congressional Budget Office estimated Wednesday that with a repeal-but-no replacement bill the number of uninsured is expected to be 17 million higher than if Obamacare remains in place. And by 2020 there would be 20 million more uninsured people, CBO said. That tally would grow to 32 million by 2026, the report said.” (A)

“President Trump did not do much to sell the Senate health care bill before its failure. But he gave the sale a shot Wednesday in the White House before cameras and a captive audience of nearly all the Republican senators. His comments were at times confusing, and in some cases, outright incorrect.
It shows the challenge for a president who doesn’t dive deeply into policy to sell his agenda.” (B)
To look at everything Trump said, with some fact checks and context: highlight and click on http://www.npr.org/2017/07/20/538171317/fact-check-trumps-confusing-remarks-to-senate-republicans-on-health-care

“….Trump claimed at the lunch that “we’re very close” to passing a repeal-and-replace bill. It was the latest sign of the disconnect between the president and the Senate. It also came a day after Trump tweeted “let ObamaCare fail” — and two days after he called for a repeal-only bill.” (C)

“Majority Leader Mitch McConnell spurred Republican senators Thursday to resolve internal disputes that have pushed their marquee health care bill to the brink of oblivion. Yet the GOP’s reeling effort to dismantle much of President Barack Obama’s health care law may face even longer odds because of Sen. John McCain’s jarring diagnosis of brain cancer.
“Dealing with this issue is what’s right for the country,” McConnell, R-Ky., said. He added, “It was certainly never going to be easy, but we’ve come a long way and I look forward to continuing our work together to finally bring relief.”
Nursing a slender 52-48 majority, McConnell has been unable to muster the 50 votes he’d need to approve his party’s health care overhaul. Vice President Mike Pence would cast the tie-breaking vote….
Aiming to finally resolve the issue, McConnell has said he’ll force a vote on the legislation early next week….” (D)

“If Collins is a no vote on any form of the legislation and Paul won’t support a replacement, and Capito and Murkowski won’t support the repeal-only approach, and Lee and Moran won’t support the replacement, and it’s unclear if McCain will be back next week … Republicans simply don’t have the votes throughout all the confusing scenarios. And that’s to say nothing of Dean Heller (R-Nev.), who has been cagey all along on any form of the legislation.” (E)

“The vote is a reward to the ultras who sabotaged repeal and replace by allowing them to posture one more time as purists who have not forsaken the true faith. It punishes the cautious senators who recoiled from huge Medicaid cuts by thrusting upon them a clear alternate they would prefer to evade. It intensifies mutual suspicion and ill-feeling inside a caucus where two senators—Nevada’s Dean Heller and Arizona’s Jeff Flake—have been explicitly threatened by the president and head of party.” (F)

“Under the humane approach, with a stronger health care system a shared goal, Republicans and Democrats would work together to fix the marketplace problems and restore confidence among insurance companies. In counties with no insurers, Congress could require the Federal Employees Health Benefits Program to offer coverage. State governments, working with the Trump administration, could create reinsurance programs to reduce the risk that insurers would lose money because of a few very sick patients. This could lower premiums and encourage insurers to operate in sparsely populated parts of the country.
If it chooses to set partisan point-scoring aside, the Trump administration would continue subsidy payments to insurers, House Republicans would drop their lawsuit and, going forward, Congress would appropriate money for these payments so that they could not be used to undermine the health care law. Quick action is needed on all fronts because insurers and state and federal regulators must finalize rates and policies for next year in the coming weeks. (G)

(A) CBO: Obamacare repeal bill would raise number of uninsured by 32 million by 2026, by Christine Wang and Dan Mangan, http://www.cnbc.com/2017/07/19/cbo-obamacare-repeal-bill-would-raise-number-of-uninsured-by-27-million-by-2020.html
(B) Fact Check: Trump’s Confusing Remarks To Senate Republicans On Health Care, by Danielle Kurtzleben, http://www.npr.org/2017/07/20/538171317/fact-check-trumps-confusing-remarks-to-senate-republicans-on-health-care
(C) Trump threatens electoral consequences for senators who oppose health bill, by Sean Sullivan, Kelsey Snell and David Nakamura, https://www.washingtonpost.com/powerpost/trump-challenges-senators-to-resurrect-obamcare-repeal-effort-were-close/2017/07/19/468c2dc0-6c8f-11e7-9c15-177740635e83_story.html?utm_term=.bd1cd4cb38f1
(D) McConnell prods senators on health care bill, amid dim odds, by Erica Werner and Alan Fram, http://abcnews.go.com/Health/wireStory/gop-senators-ditch-rescue-health-care-bill-48740322
(E) Senate Republicans Report New Life On Their Health Care Bill, by Matt Fuller, http://www.huffingtonpost.com/entry/senate-republicans-new-life-health-care_us_59702f8be4b0aa14ea7711b7
(F) The Paradox of Mitch McConnell’s Repeal-Only Vote, by David Frum, https://www.theatlantic.com/politics/archive/2017/07/the-paradox-of-mitch-mcconnells-repeal-only-vote/534129/
(G) The Trumpcare Bonfire, https://www.nytimes.com/2017/07/18/opinion/trumpcare-obamacare-let-it-fail.html?smprod=nytcore-ipad&smid=nytcore-ipad-share

“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