DAVID GREENE, HOST:
The Republican health care bill met its demise last night. Senators Mike Lee and Jerry Moran simultaneously announce their opposition to the replacement for the Affordable Care Act. President Trump took to his own Twitter, saying, "Republicans should just repeal failing Obamacare now and work on a new health care plan that will start from a clean slate. Dems will join in," end quote. NPR's Susan Davis has been covering every twist and turn in this. And she's in our studios. Hi, Sue.
SUSAN DAVIS, BYLINE: Good morning, David.
GREENE: So let's step back here. Republicans have been promising to repeal and replace for seven years. You'd think they've had some time to think about how best to do that. Why did this bill fall short?
DAVIS: It fell short because they just could not simply find a consensus on what repeal and replace ultimately looked like. Repeal and replace was always a good slogan. And, you know, it did deliver victories. It helped win them control of the House and the Senate and, eventually, the White House. But when they had to put pen to paper and illuminate what a Republican vision of the individual market should look like, they just couldn't find consensus. And part of that is also the reality of having a very, very narrow majority in the United States Senate. There's only 52 Republican votes. They had very little room for error. And in the end, they just couldn't get there.
GREENE: So what happens now? Mitch McConnell's talking about maybe the Republican leadership just repealing and then worrying about replacing later and then maybe working with Democrats. Is that - is that a realistic path?
DAVIS: You know, I think Mitch McConnell, the Senate majority leader, knows that he has to have a vote on this one way or another. He has said that, at some point to be determined - he hasn't said when - that there are going to, again, have a procedural vote just to get on the bill - just to say, hey, we're ready to start debating this issue. Huge question mark if they can even get those 50 votes. And then he has said, if they can get on it, the first vote will be repeal only - which is what the president is calling for.
In a way, he's sort of calling people's bluff. This was a strategy that a lot of Republicans had supported in the beginning of the year. They eventually decided that was not a good idea, to take away health care and not be able to illuminate what you would - could replace it with. I think it's more of a political move than a policy one. But it'll be interesting to see where the votes fall.
GREENE: But that's important here. So you're saying there is even some uncertainty in that - that he could muster enough votes to just do a straight-up repeal.
DAVIS: Absolutely because if you're saying, this is going to be the first vote we have, there's - remember, you know, that's a move to appeal to a lot of conservatives. But a lot of moderate Republicans, like Susan Collins of Maine, a senator we've heard a lot about in the recent weeks, are unlikely to get behind that strategy. So again, there is really no one plan that can get 50 senators on board.
GREENE: How bad is this in terms of a setback for the entire Republican agenda?
DAVIS: You know, we don't know for sure. But I can tell you what Republicans have told me repeatedly in recent weeks, that they saw failure here as potentially devastating to the rest of the Republican agenda in terms of getting tax reform done, which is arguably a bigger priority for many in the party than health care - in terms of getting an infrastructure bill done or moving any big legislative lifts.
If you can't do the one thing that, in theory, unified the entire party, how can you do even harder things? I think there's a fear that failure here will be sort of internally corrosive, will prompt some element of party infighting and that - I think it also shows there's still a lot of distance and potentially some distrust between Republicans in Congress and their president in the White House.
GREENE: So let me ask - let me just ask you a broad question here. Matthew Continetti - he's a conservative writer, the editor of The Washington Free Beacon. He was on our show this morning. He said that health care is not the Republicans' issue. I asked him, do you mean that Americans shouldn't trust Republicans on health care? He said, no, no, no, just politically, it's a bad issue. Do you hear that from Republicans?
DAVIS: You know, I do. I mean, health care is an issue I don't think is in the marrow of the Republican Party's bones in the same way it is for the Democratic Party. And also, you know, fundamentally, if you think of the way these debates were framed, the Affordable Care Act was about giving people something. And this Republican health care bill was about taking something away. And that's always going to be a more difficult sell to the American electorate when they perceive that their government is taking something from them.
STEVE INSKEEP, HOST:
OK, so NPR's Susan Davis is here. And let's bring another voice into the conversation now to ask, in this intricate debate, what are some of the facts that are most relevant now. Larry Levitt joins us by Skype. He's senior vice president of the Kaiser Family Foundation, which studies health care and is separate, by the way, from the insurance company, Kaiser Permanente. Mr. Levitt, welcome to the program.
LARRY LEVITT: Thanks, good morning.
INSKEEP: So what does this latest collapse mean for the health care industry?
LEVITT: Well, the health care industry, and particularly insurance companies, will be looking intently at how the Trump administration reacts to this. The Affordable Care Act is still the law of the land. Insurers have to set premiums for 2018 and decide whether they're going to participate in the insurance marketplaces. And they're looking and reading the tea leaves to see what the Trump administration is going to do following this failure.
INSKEEP: OK. So before we even get to the longer term prospects for Obamacare, there's this real-time decision that insurance companies are making now about whether to participate in the health care market in - I don't know - Idaho, Kentucky. Pick your state.
LEVITT: Absolutely. And there are two things in particular insurers are looking for. One is whether the administration will enforce the individual mandate. That's the stick that compels healthy and young people to sign up for insurance or pay a penalty. And then the second is whether the administration will pay what's known as cost-sharing subsidies. Insurers under the law have to provide lower deductibles to low-income consumers. And these subsidies compensate insurers for that cost.
In the past, the president has threatened to withhold those subsidies, which are the subject of a lawsuit, to try and bring insurers to the table to negotiate a bill. Well, there's not a bill to negotiate right now. And insurers, if they don't get that money, would have to raise premiums significantly, or might just pull out of the market altogether.
INSKEEP: OK. So the administration can do things right now or not do things right now that could cause premiums to go up or could cause more or fewer choices for people in different insurance markets. You mentioned, though, that what the Trump administration does is being closely watched. There is something that the guy at the top of the Trump administration has already done. He has publicly said, as we heard David and Sue discuss - he's publicly said, go ahead with repeal. Just repeal it. Work on replacement later.
And Mitch McConnell, the Senate majority leader, has effectively said they're going to try that. They're going to attempt that. What are the implications for the insurance market if that worked - if there's a straight repeal, if there's no replacement and a two-year deadline and Congress says, we'll work something out over the next couple of years?
LEVITT: There's an important fact to know about this repeal. It's not actually a full repeal because Republicans can't do that under the budget rules they're operating in for this debate. So...
INSKEEP: Oh, this is just a partial repeal at best. OK.
LEVITT: This is a partial repeal. It repeals the subsidies that help people buy insurance. It repeals the Medicaid expansion. It repeals all of the taxes. And it repeals the individual mandate, in fact, retroactively. What it doesn't do is repeal the requirement on insurers that they take everyone, including people with preexisting conditions.
INSKEEP: Meaning that over the next couple of years, insurers would still have to take anybody.
LEVITT: Exactly. Insurers would have to take anyone. People would not get subsidies to help them buy insurance. And there would be no individual mandate to compel healthy people to sign up. So what the Congressional Budget Office has said is that premiums would immediately go up 20 to 25 percent next year, and eventually double by 2026. And the number of people uninsured would rise by 18 million initially and eventually by 32 million.
INSKEEP: Wait a minute. Wait a minute. We're talking about they'll repeal with a two-year delay. Are you saying even before the two-year period ended, that premiums would start soaring? That would be the practical effect here?
LEVITT: Exactly - because the individual mandate would be repealed immediately. So insurers would have to take people with preexisting conditions. But the sense is healthy people without that mandate wouldn't sign up. So insurers, under that kind of uncertainty, would immediately raise premiums.
INSKEEP: Stick with us for a moment, Larry Levitt, because I want to bring Susan Davis back into our conversation. She's been covering the politics of all this. And I'd like to know, Sue - Republicans have voted again and again and again for straight-up repeal - repeal of Obamacare. They did it just a couple of years ago. How eager, actually, are Republicans to just repeal Obamacare?
DAVIS: Well, we may have - we may find out very soon. And it's not - I would not say it's the vast majority of Republicans. They like the idea of repeal. But the reason why they scuttled this original plan back in January is they realized it was tremendously risky to repeal legislation and not be able to tell the public what you're going to do with it. And remember, Congress does not do well when they say they're going to do things with big consequences.
INSKEEP: (Laughter).
DAVIS: The last time they did this, they tried to get a budget deal. And it resulted in painful budget cuts known as the sequester.
INSKEEP: Which they've hated ever since. Larry Levitt is still on the line. And let me ask about another option here, which Mitch McConnell has discussed. Suppose, as McConnell once said, Republicans are finally forced to work with Democrats, come up with some kind of bipartisan plan. And then we're talking about options that improve choices for people in the health insurance market, hopefully lead to cheaper premiums. What bipartisan options are out there, potentially?
LEVITT: Well, there are ideas that both Democrats and Republicans have talked about. One is providing insurance that these cost-sharing subsidies get paid to insurers. The other is pumping some money into the insurance market to help lower premiums and reduce the uncertainty insurers have in covering high-cost patients.
INSKEEP: Wait a minute, paying more? Because Republicans are not going to like that.
LEVITT: Well, you know, interestingly enough, all of the Republican bills included a substantial amount of money to funnel money to insurers to help bring premiums down. So there's at least some on-paper bipartisan support for that idea.
INSKEEP: And then it just becomes a matter of getting the numbers - getting agreement on the numbers?
LEVITT: Exactly, and figuring out what to do about this individual mandate because it's - you know, that's something Democrats are wedded to to stabilize the insurance system. And Republicans have been consistently opposed to that.
INSKEEP: Larry Levitt, thanks very much. Really appreciate it.
LEVITT: Thank you.
LEVITT: He is senior vice president of the nonprofit Kaiser Family Foundation. He spoke with us by Skype from Oakland, Calif. And we also, of course, heard from NPR's Susan Davis. Transcript provided by NPR, Copyright NPR.