Joyce Frieden reported that in a session that lasted into the wee hours of Friday morning, the Senate voted down a “skinny” bill to repeal the Affordable Care Act (ACA), dealing a big blow to the chamber’s Republican leadership.First of all, what a dumb name for the bill! Who in their right mind would vote for a “Skinny” Health Care Bill?

The vote was 49-51 to defeat the bill — known as the Health Care Freedom Act — which would have repealed the employer and individual mandates but would have left other elements of the ACA in place. It also would have defunded Planned Parenthood and repealed the medical device tax. Along with all of the Senate’s Democrats and its two Independents, three Republicans — John McCain of Arizona, Lisa Murkowski of Alaska, and Susan Collins of Maine — also voted against the bill.

“This is a disappointment, a disappointment indeed,” Senate Majority Leader Mitch McConnell (R-Ky.) said after the vote. “I regret that our efforts were simply not enough this time.”

“I imagine many colleagues on the other side are celebrating, but the American people are hurting and they need relief,” he continued. “Now I think it’s appropriate to say, ‘What are [Democrats’] ideas?’ It will be interesting to see what they suggest as the way forward.” He immediately knocked down one idea: “Bailing out insurance companies with no thought of any kind of reform — that’s not something I want to be part of, and I suspect there are not many folks over here that are interested in that.”

Senate Minority Leader Chuck Schumer (D-N.Y.) adopted a conciliatory tone. “I’d say to [McConnell] that we’re not celebrating; we’re relieved that the millions of people who would be so drastically hurt by the proposals put forward will be able to maintain their healthcare,” he said. “But as I have said over and over again, Obamacare is hardly perfect. It did a lot of good things but it needs improvement.”

“I would suggest we turn the page … And I hope one part of turning the page is we go back to regular order and work [together] to improve Obamacare,” he continued. “There are suggestions we’re interested in that come from the other side of the aisle. So let’s turn the page and work together to improve our healthcare system.”

Democrats Oppose the Measure! Any surprise in this vote?

Senate Minority Leader Chuck Schumer (D-N.Y.) urged Republicans to vote against the bill. “Listen to what the CBO said; it said that skinny repeal would cause 16 million Americans to lose insurance and millions would pay 20% more for premiums starting next year — not 3 years from now but in January,” he said. “One of the promises Republicans made was to bring down premiums, but this would break that promise.”

“You don’t vote to advance terrible legislation and hope it gets better in conference,” he added. “Let’s not forget — months ago the House voted to pass their bill because they hoped it would get better in the Senate. Well, it hasn’t gotten better yet.”

Sen. Sheldon Whitehouse (D-R.I.) pointed out that most medical organizations opposed the bill. “Who did the magicians who came up with this listen to? They obviously didn’t listen to the doctors,” he said. “The American Medical Association is opposed, the American Academy of Family Physicians is opposed to this bill … the American Heart Association is opposed to this bill … Rural hospitals are warning that this could end their very existence.”

And a Single-Payer version was also shot down!

Before the skinny repeal bill was debated, the Senate voted on a single-payer bill introduced by Sen. Steve Daines (R-Mont.). “The amendment I’m putting forward here today is … a carbon copy, down to every last comma and period, of Rep. [John] Conyers’ [single-payer House] bill, which has 115 Democratic cosponsors as I speak.”

“I believe Montanans and the American people deserve to debate different ideas,” said Daines. “Earlier today Sen. [Bernie] Sanders suggested that my amendment was intended to embarrass Democrats. Sen. Sanders, my amendment shouldn’t embarrass anyone; I’m trying to show the American people who is supportive of socialized medicine and who is not. Tell the American people what you think. I think we should vote No on this; what say you?”

Sanders decried Daines’ move as a “political trick” to force some Democratic senators into an uncomfortable political position. “I hope this is really a breakthrough on the part of my Republican colleagues,” he said. “I hope they recognize that the U.S. should join every other major country on earth in recognizing that healthcare is a right, not a privilege.”

“I hope that’s what Mr. Daines will be saying, but I kinda think that’s not what he’ll be saying,” said Sanders. “If Mr. Daines is serious, let us work together, but now is not a time for political games.”

Daines’ bill failed 57-0, with Sanders, an independent, and 42 Democrats voting “present”. Besides all 52 Republicans, those voting No included Sen. Angus King (I-Maine) and Democrats Joe Manchin of West Virginia, Jon Tester of Montana, Heidi Heitkamp of North Dakota, and Joe Donnelly of Indiana.

The Daines bill “was an explicit ruse, intended to waste some of the 20 hours of debate time and an attempt to taunt and then ’embarrass’ Democrats into formally admitting that they are all socialists,” said Jay Wolfson, DrPH, JD, associate vice president of USF Health, in Tampa, Fla., in an email to MedPage Today. “It was an old state legislative trick in which a member introduces a bill and then votes against it. Single-payer is not achievable in the current Congress in any event.”

“Cadillac Tax” Repeal Passes

The Senate also voted down an amendment by Sen. Luther Strange (R-Ala.) to make the premium tax credits offered through the Affordable Care Act subject to the Hyde Amendment, which bars federal funds from being spent on abortion. The amendment, which required 60 votes to pass, went down by a vote of 50-50.

They did pass one amendment, which was to repeal the “Cadillac tax” on high-cost health insurance plans. The amendment passed by a vote of 52-48.

As the day wore on, some Republican senators expressed their misgivings about the skinny repeal bill. “We’ve been asked by the leadership … to vote for the ‘least common denominator,'” Sen. Lindsey Graham (R-S.C.) said at a news conference at which he appeared with Sen. Ron Johnson (R-Wisc.) and McCain. “The pitch is if we go to conference, we can get my [alternative] bill scored, we can get Sen. [Ted] Cruz’s bill scored … That makes eminent sense to me, with one condition — that we actually go to conference.”

On the other hand, Graham added, “The skinny bill as policy is a disaster; it’s not a replacement in and of itself.” He particularly objected to the bill’s elimination of the employer mandate, which he said would increase premiums while keeping most of the ACA in place. “And we politically own the collapse of healthcare. So we’re not going to do that with our vote. What we’ll do is move the process along.”

House Speaker Paul Ryan issued a statement Thursday that appeared to be intended to reassure anxious senators — but with some caveats. “If moving forward requires a conference committee, that is something the House is willing to do,” he said.

“The reality, however, is that repealing and replacing Obamacare still ultimately requires the Senate to produce 51 votes for an actual plan. The House remains committed to finding a solution and working with our Senate colleagues, but the burden remains on the Senate to demonstrate that it is capable of passing something that keeps our promise, as the House has already done. Until the Senate can do that, we will never be able to develop a conference report that becomes law.”

The defeat of the Senate bill capped a difficult few days for Senate Republicans. On Tuesday, things were looking up when senators narrowly voted to proceed with a debate on a repeal bill, although it was not yet clear which bill that would be. But on Wednesday, the Senate voted down two bills — first a bill to repeal the ACA without a replacement, and then a second bill — the Better Care Reconciliation Act — to repeal and replace the law.

As the title of this blog post suggests this lack of progress shouldn’t be a surprise considering that States have already tried versions of ‘Skinny Repeal’ and it didn’t go well! J. Scott Applewhite from the AP in his latest article reviewed this bit of history. Betting that thin is in — and might be the only way forward — Senate Republicans are eyeing a “skinny repeal” that would roll back an unpopular portion of the federal health law. But health policy analysts warn that the idea has been tried before, and with little success.

Senators are reportedly considering a narrow bill that would eliminate the Affordable Care Act’s “individual mandate,” which assesses a tax on Americans who don’t have insurance. The bill would also eliminate the ACA’s penalties for some businesses – those that have 50 or more workers and fail to offer their employees health coverage.

Details aren’t clear, but it appears that — at least initially — much of the rest of the 2010 health law would remain, under this strategy, including the rule that says insurers must cover people who have pre-existing medical problems.

In remarks on the Senate floor Wednesday, Sen. Minority Leader Charles Schumer, D-N.Y., said that “we just heard from the nonpartisan Congressional Budget Office that under such a plan … 16 million Americans would lose their health insurance, and millions more would pay a 20 percent increase in their premiums.” The CBO posted its evaluation of the GOP’s proposed plan Wednesday evening.

Earlier in the day, some Republicans seemed determined to find some way to keep the health care debate alive.

“We need an outcome, and if a so-called skinny repeal is the first step, that’s a good first step,” said Sen. Thom Tillis, R-N.C.

Several Republican senators, including Dean Heller of Nevada and Jeff Flake of Arizona, appear to back this approach, according to published reports. It is, at least for now, being viewed as a step along the way to Republican health reform.

“I think that most people would understand that what you’re really voting on is trying to keep the conversation alive,” said Sen. Bob Corker, R-Tenn. “It’s not the policy itself … it’s about trying to create a bigger discussion about repeal between the House and Senate.”

But what if, during these strange legislative times, the skinny repeal were to be passed by the Senate and then go on to become law? States’ experiences with insurance market reforms and rollbacks highlight the possible trouble spots.

Let’s consider the parallels.

By the late 1990s, states such as Washington, Kentucky and Massachusetts felt a backlash when some of the coverage requirement rules they’d previously put on the individual market were lifted. “Things went badly,” said Mark Hall, director of the health law and policy program at Wake Forest University.

Premiums rose and insurers fled these states, leaving consumers who buy their own coverage (usually because they don’t get it through their jobs) with fewer choices and higher prices.

That’s because — like the Senate plan — the states generally kept popular parts of their laws, including protections for people with pre-existing conditions. At the same time, they didn’t include mandates that consumers carry coverage.

That goes to a basic concept of any kind insurance: People who don’t file claims in any given year subsidize those who do. Also, those healthy people are less likely to sign up, insurers said, and that leaves insurance companies with only the more costly policyholders.

Bottom line: Insurers end up “less willing to participate in the market,” said Hall.

It’s not an exact comparison, though, he added, because the current federal health law offers something most states did not: significant subsidies to help some people buy coverage. Those subsidies could blunt the effect of not having a mandate.

During the debate that led to the passage of the federal ACA, insurers flat-out said the plan would fail without an individual mandate. On Wednesday, the Blue Cross Blue Shield Association weighed in again, saying that if there is no longer a coverage requirement, there should be “strong incentives for people to obtain health insurance and keep it year-round.”

Survey says-individual mandate is still unpopular in voter polls!

About 6.5 million Americans reported owing penalties for not having coverage in 2015.

Polls consistently show, though, that the individual mandate is unpopular with the public. Indeed, when asked about nine provisions in the ACA, registered voters in a recent Politico/Morning Consult poll said they want the Senate to keep eight, rejecting only the individual mandate.

Even though the mandate’s penalty is often criticized as not strong enough, removing it would still affect the individual market.

“Insurers would react conservatively and increase rates substantially to cover their risk,” said insurance industry consultant Robert Laszewski.

That’s what happened after Washington state lawmakers rolled back rules in 1995 legislation. Insurers requested significant rate increases, which were then rejected by the state’s insurance commissioner. By 1998, the state’s largest insurer — Premera Blue Cross — said it was losing so much money that it would stop selling new individual policies, “precipitating a sense of crisis,” according to a study published in 2000 in the Journal of Health Politics, Policy and Law.

“When one pulled out, the others followed,” said current Washington Insurance Commissioner Mike Kreidler, who was then a regional director in the federal department of Health and Human Services. The state’s individual market was volatile and difficult for years after. Insurers did come back, but won a concession: For a time, the insurance commissioner lost the power to reject rate increases. Kreidler, first elected in 2000, reclaimed that authority.

Predicting the effect of removing the individual mandate is difficult, although Kreidler said he expects the impact would be modest, at least initially. Subsidies that help people purchase insurance coverage — if they remain as they are under current law — could help blunt the impact. But if those subsidies are reduced — or other changes are made that further drive healthy people out of the market — the impact could be greater.

“Few markets can go bad on you as fast as a health insurance market,” said Kreidler.

As for employers, dropping the requirement that those with 50 or more workers must offer health insurance or face a financial penalty could mean some workers would lose coverage. But their jobs might be more secure, said Joseph Antos, a health care economist and resident scholar at the American Enterprise Institute.

That’s because the requirement under the ACA meant that some smaller firms didn’t hire people or give workers more than 30 hours a week — the minimum needed under the ACA to be considered a full-time worker who qualified for health insurance.

The individual mandate, he added, may not be as much of a factor in getting people to enroll in coverage as some think because the Trump administration has indicated it might not enforce it anyway — and the penalty amount is far less than most people would have to pay for health insurance.

However, the individual market could be roiled by other factors, Antos said. “The real impact would come if feds stopped promoting enrollment and did other things to make the exchanges [— the state and federal markets through which insurance is offered —] work more poorly.”

“Couple caught in ‘financial spiral’ jump to their deaths.” And the media plays up the tragedies so people believe that health care reform is the problem. Consider this latest suicide reported by Shawn Cohen, Tamar Lapin and Natalie Musumeci. A pair of Manhattan parents claiming financial woes jumped to their deaths early Friday — leaving double suicide notes pleading that their two kids be cared for, law enforcement sources told The Post.The bodies of 53-year-old chiropractor Glenn Scarpelli and his wife, 50-year-old Patricia Colant, were found in the middle of the street on 33rd Street between Park and Madison avenues in Murray Hill after the pair jumped from the ninth-floor window of a 17-story corner office building on Madison Avenue at about 5:45 a.m., police said. Glenn, whose office was on the same floor of the building where the couple jumped, titled the suicide note found in his pocket, “WE HAD A WONDERFUL LIFE.” It was typed on a piece of white paper. His wife also had a suicide note in her pocket that read, “in sum and substance,” according to a source, “‘Our kids are upstairs, please take care of them.’” “Patricia and I had everything in life,” the man’s note read. But it also touched on the couple’s “financial spiral” and how “we can not live with” the “financial reality,” sources said. A law enforcement source at the scene told The Post that authorities at first believed that the couple struggled with health care costs. But an NYPD spokesman said later that there was no mention of medical-cost struggles in the notes. The couple was in debt, another source said.

Most physician organizations expressed gratitude and relief following the Senate’s early-morning defeat on Friday of a bill to partially repeal the Affordable Care Act (ACA).”The American College of Physicians (ACP) applauds the Senate for voting to reject the ‘skinny’ ACA repeal legislation that would have greatly harmed our patients,” ACP president Jack Ende, MD, said in a statement. “This legislation … would have put tens of millions of Americans at risk of losing health insurance coverage, and all Americans at risk of losing critical patient protections.”

“No version of legislation brought up this year would have achieved the types of reforms that Americans truly need: lower premiums and deductibles, with increased access to care,” he continued. “We now urge the House and the Senate to move forward in a bipartisan manner, working through ‘regular order,’ to make improvements to the ACA.”

The vote was 49-51 to defeat the bill — known as the Health Care Freedom Act — which would have repealed the employer and individual mandates but would have left other elements of the ACA in place. It also would have defunded Planned Parenthood and repealed the medical device tax. Along with all of the Senate’s Democrats and its two Independents, three Republicans — John McCain of Arizona, Lisa Murkowski of Alaska, and Susan Collins of Maine — also voted against the bill.

“This is a disappointment, a disappointment indeed,” Senate Majority Leader Mitch McConnell (R-Ky.) said after the vote. “I regret that our efforts were simply not enough this time.”

The American Medical Association (AMA) focused on the future in its short statement, issued minutes after the final vote. “While we are relieved that the Senate did not adopt legislation that would have harmed patients and critical safety net programs, the status quo is not acceptable,” said AMA president David Barbe, MD. “We urge Congress to initiate a bipartisan effort to address shortcomings in the Affordable Care Act. The first priority should be to stabilize the individual marketplace to achieve the goal of providing access to quality, affordable health coverage for more Americans.”

“On behalf of the patients we care for, we thank the Senate for voting to protect the health of millions of Americans — including those on Medicaid and with preexisting conditions — whose coverage was in jeopardy,” Darrell Kirch, MD, president, and CEO of the Association of American Medical Colleges, said in a statement. “Now it is more important than ever that Congress and the administration work together to improve the current system and ensure that all Americans have access to affordable, comprehensive coverage. The most immediate concern is stabilizing the health insurance market through continued, predictable funding of cost-sharing subsidies.”

The American Academy of Pediatrics (AAP) was grateful that the Senate defeated the bill but also had other concerns. “Our work is not over,” said AAP president Fernando Stein, MD, in a statement. “We turn now to the looming reauthorization of the Children’s Health Insurance Program, a bipartisan success story providing coverage for nearly 9 million children. We turn now toward other pressing issues that matter for children, like child welfare reform, with renewed resolve.”

Some health policy experts were surprised by the vote’s trajectory. “Last night’s vote to me was something that I never thought I would see: people being asked to pass clearly a bad piece of legislation just to keep the process going,” Paul Ginsburg, PhD, director of the USC-Brookings Schaeffer Initiative for Health Policy, told MedPage Today in an interview. “I’m amazed that it still got 49 votes, because so many Republicans had been so critical of ‘skinny repeal’ on its own … I think it had gotten to a point of absurdity.”

The next step for Congress is to find a way to manage the immediate problem of struggling markets in certain areas of the country, said Ginsburg, who is a member of the Medicare Payment Advisory Commission (MedPAC) but was speaking for himself. “The one thing they are most likely to agree on is reinstating reinsurance” — insurance policies to cover costs for health insurers who end up with unexpectedly high-cost patients. Republicans in Congress aren’t likely to be inclined to let the ACA fail, he said, because “sabotaging” the insurance markets could hurt them in the next election.

Ginsburg also said he wouldn’t be surprised if more states chose to adopt the Medicaid expansion — broadening eligibility to those just above the poverty line.

In the vote’s aftermath, “I think that debate [over] how Medicaid should be financed and structured is probably forever with us,” said Diane Rowland, ScD, executive vice president of the Kaiser Family Foundation, in an interview. She noted that the Trump administration still has a lot of discretion to influence the program through waivers that could include the use of cost-sharing and work requirements.

Trying to pass a skinny repeal bill in the first place was a “fool’s errand,” according to Bob Laszewski, president and founder of Health Policy and Strategy Associates, an Alexandria, Va. consulting firm. “How did McConnell think he was going to do any better bringing 240 House Republicans — including the Freedom Caucus — into a process that he could get no more than 45 Republican votes for in his own Senate?” he wrote in a blog post.

For a bipartisan solution to emerge, two conditions must be satisfied, Laszewski said. First, “Democrats will have to admit the problems with Obamacare are more than ‘imperfections’ — they will have to admit that Obamacare has been a dismal failure for those who have no choice but to buy their health insurance in the individual health insurance market and make too much money to qualify for a subsidy.”

And second, “Republicans will have to admit that most American households not eligible for Medicare, employer-based health insurance, or the pre-2014 Medicaid program, cannot afford to buy health insurance on their own — even if we had 2013 premium rate levels.” I believe that we all knew that this GOP couldn’t create a health care system that would first be approved by the Democrats and second to substitute for the ACA, even with the ACA’s problems.

Now Bernie Sanders said today that he would introduce a single payer health care system. Sen. Bernie Sanders (I-Vt.) said Sunday that he will “absolutely” introduce legislation on single-payer healthcare now that the Senate GOP’s bill to repeal ObamaCare has failed. Let’s look at the single payer health care system next week. Are we ready for it??

I’ll leave you with the Gordon Lightfoot lyrics the Paul Ryan recited for the “Sinking of the Wreck of the Edmund Fitzgerald” :

“The ship was the pride of the American side
Coming back from some mill in Wisconsin
As the big freighters go, it was bigger than most
With a crew and good captain well seasoned
Concluding some terms with a couple of steel firms
When they left fully loaded for Cleveland
And later that night when the ship’s bell rang
Could it be the north wind they’d been feelin’?

The wind in the wires made a tattle-tale sound
And a wave broke over the railing
And every man knew, as the captain did too,
T’was the witch of November come stealin’
The dawn came late and the breakfast had to wait
When the gales of November came slashin’
When afternoon came it was freezin’ rain
In the face of a hurricane west wind

When suppertime came, the old cook came on deck sayin’
Fellas, it’s too rough to feed ya
At seven pm a main hatchway caved in, he said
Fellas, it’s been good t’know ya
The captain wired in he had water comin’ in
And the good ship and crew was in peril
And later that night when his lights went outta sight
Came the wreck of the Edmund Fitzgerald”

What’s next? As I said let’s discuss the Single Payer System, which the Democrats missed out in getting their eventual wish!