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Coffee CAHC policy round-up: March 17, 2017

Coffee CAHC is a twice-weekly newsletter where we round up and comment on the latest health coverage policy developments both nationally and here in Maine. We hope you find these updates helpful!

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Coffee CAHC

115th Congress, 1st session

128th Maine Legislature, 1st session


March 17, 2017


Good morning, readers! I assume that today you’re all wearing green and making boiled dinner for…well, for dinner, and perhaps even indulging in a green beer or two, and other vaguely “Irish” things we’ve come to associate with St Patrick’s Day? I am dutifully wearing my greenest sweater to appease my Irish-American ancestors, and there’s corned beef in my near future. That’s about as exciting as my weekend plans get, because I’m also recovering from this brutal cold/flu/plague “viral thing” that’s been flying around. But there’s enough strength left in me to make sure you all get a heaping helping of Coffee CAHC!


National level

I’ve been writing Coffee CAHC for almost three months now*. In that entire span, I don’t think there’s ever been such a big shift in the landscape in the 48 hours between the Wednesday and Friday editions as what we’re seeing this week.

When I wrote to you on Wednesday morning, the posture in DC was still Speaker Paul Ryan holding firm that the bill would have to be passed exactly as-is, the Trump Administration standing behind that position, the bill set to sail through the Budget Committee without a sweat, and the odds of that bill passing in the Senate looking pretty shaky at best.

By Wednesday evening, the President had threatened not to sign the bill (after seemingly acknowledging that areas of the country that voted for him would be much worse off under the replacement), Speaker Ryan had come out and said he was completely open to changes; on Thursday, the bill barely squeaked through the Budget Committee on a 19-17 vote when three conservative Republicans voted against it; and this morning, the Press Herald reported that Senator Susan Collins is now saying she will not support the bill as written, changing those Senate odds from “shaky” to something more like “on life support”.

The central tension in this entire enterprise boils down to this: the bill almost certainly has to be made more moderate to pass the Senate; it definitely has to be made more conservative to pass the House. It is getting harder and harder to see how Congressional leadership finds a balance that gets them to 216 votes in the House, and 51 (even if that means a 50-50 tie broken by Vice President Pence) in the Senate.

One of the key promises that Speaker Ryan has made all along on this bill has been that this package is just the first step in a multi-stage process, a so-called “three-prong approach.” The first step is pass this package through reconciliation in the Senate (requiring only 51 votes instead of 60 to break through a filibuster). The second step is the Administration taking regulatory action to dismantle other pieces of the ACA. The third step is passing additional legislation to “clean up” the changes they want to make, but can’t through reconciliation (which, remember, must have an impact on the budget in order to fly). Sarah Kliff covers exactly what the problems are with this plan, and we’re seeing the first major one right now: they don’t seem to be getting any closer to passing the first prong, let alone getting to the second or third.

Still, make no mistake: this legislation is not dead yet. Not even close. In fact, if all goes according to the current plan, the bill will get through the Rules Committee next week and then on to the House floor for a vote, possibly on March 23rd (the 7th anniversary of the passage of the ACA). My assumption is that leadership will do a tight enough whip count to only let something on the floor that they know will pass: it would be a body blow to move a package on the floor and lose on a straight up-or-down because of defections in their own ranks.

Despite all the problems, despite the fluidity of the situation overall, I don’t want to understate this key fact: this bill has moved through the process with barely a hiccup, and it’s entirely possible that by the end of next week, one chamber of Congress will have given their stamp of approval to repealing and replacing the ACA.

Things have slowed down dramatically, and things certainly look better than they did a few months ago, but we can’t overlook the breathtaking damage that will be done to the American health care system if this bill passes (or even if something passes that is only a shadow of this bill). The hesitation we’re seeing in Congress is certainly due at least in part, probably even due in large part, to the pressure that has been placed on Senators and Representatives not to charge ahead with something so dramatically, blatantly harmful to their constituents’ well-being. We’re doing well so far, but we simply can’t let up.

*I can’t believe Coffee CAHC is almost three months old!


State level

On Wednesday, I teased a possible exciting tidbit for you all today – and, dear readers, let it never be said that I don’t pull through for you. You’re among the first to see the results of some recent polling that was done in Maine about the ACA and the GOP replacement plan. You can check out all of the polling results here, but let me highlight a few things for ya:

  • 60% of respondents feel that “Congress should keep what works in the [ACA] and fix what doesn’t”, rather than repeal the entire thing and start over;
  • Nearly 60% have a “somewhat” or “very” unfavorable view of the GOP replacement plan;
  • Not a single key component of the replacement plan was viewed favorably by a majority of respondents;
  • Among the specific components of replacement, 84% are opposed (“strongly” or “very”) to increasing age rating bands to a 5:1 ratio, and a whopping 74% are strongly opposed (and a further 9% somewhat opposed) to letting insurers get a tax break for CEO salaries;
  • Strong majorities are opposed to ending Medicaid expansion.

We don’t always get to see robust state-level polling on issues like this in Maine, so this is pretty fascinating. There’s some other stuff in there, but overall, it’s pretty bleak reading for anybody who favors the replacement package.

In the Maine Legislature, one thing to keep an eye on is that the Health and Human Services committee is wrapping up their work on their portions of the budget this week. They’ll be writing a committee report back to the Appropriations Committee, who ultimately decides what does and doesn’t get recommended in the budget package that will move to the full Legislature for consideration. These committee reports are important, though: Appropriations takes the recommendations of the policy committees very seriously as they craft the final budget package. We’ll have more on this as we see what ends up in the final HHS report. Remember, this is the section of the budget where the Governor is proposing big cuts to MaineCare eligibility.


Would you like to know more?

Our friends at Kaiser Family Foundation have done a terrific explainer of the per capita caps provision in the GOP replacement plan, which gets into exactly what this plan would do to Medicaid (short story: gut it).

Shameless self promotion alert! I was part of a roundtable yesterday with Senator Angus King in Brunswick where we talked about the impact of the ACA and the GOP replacement plan on Mainers, especially Mainers over the age of 50. The Senator’s staff livestreamed the event and you can watch the video on Facebook. (Please excuse the part where I said I thought about a dozen states have not expanded Medicaid: it’s actually 19 states that still have not expanded. Blame it on my flu/cold recovery, or just wishful thinking on my part!)

Finally, one quick clarification from Wednesday’s edition: I said the replacement bill would need 218 votes to pass the House. That’s typically true, except that there are currently 5 vacancies in the chamber. Since passage in the House requires only a majority of current members (not total number of seats), the magic number for passage is 216, not 218. Apologies for anybody out there who has to redo their whip sheets!


Until next time, friends, I remain,



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