The cruel reality of high-speed health care legislating

Four days ago, Senate Republicans got their first glimpse at their leadership’s plan to repeal and replace Obamacare.

Three days from now, Senate Republicans are expected to vote on that plan.

Let that sink in for a moment: We are already more than halfway through the Senate Republicans’ consideration of their health care bill — and there’s still a lot we don’t know about it, and what it would do.

The Senate is running its health care process at breakneck speed. Republicans are aiming to introduce the bill, have it scored by the Congressional Budget Office, and vote on it in exactly one week. It is a compressed and highly unusual process, which some Republicans are rebelling against.

“We don’t have enough information,” Sen. Ron Johnson (R-WI) told NBC’s Meet the Press on Sunday. “I don’t have the feedback from constituencies who will not have had enough time to review the Senate bill. We should not be voting on this next week.”

Legislating so quickly means that fewer people will have time to offer feedback and shape the bill — especially those who stand to be affected by the bill’s overhaul of the American health care system.

At the same time, the speed of the process appears to have produced some sloppy bill-writing. When it was unveiled Thursday, the Senate bill included glaring omissions in how it constructs an insurance market, which experts said could have caused that market to collapse. New policies were added over the weekend to patch those holes, but the public has not seen them.

Other policy concerns are being discovered by the day — like that this bill might raise small business insurance premiums — as analysts scramble to make sense of the document.

I’ve heard from multiple former Republican aides, who served either for the Bush administration or on Capitol Hill, who were shocked to see such large omissions. Writing good policy takes time and deliberation, especially when it is something as complex as re-regulating the health insurance marketplace.

Considering policy takes time, as well. On Sunday at a Koch donor retreat in Colorado, Sen. Ben Sasse (R-NE) was asked onstage if he would vote for the bill. He refused to take a position — in part, he said, because he had only read about 40 percent of the text.

At the same event, Sen. John Cornyn (R-TX) told reporters the hasty process was necessary in order to ensure stability in the individual health insurance exchanges created under the Affordable Care Act, which he said were in “meltdown.” But while the exchanges are being unsettled by deliberate actions from the Trump administration, they are nowhere near melting down.

The real reason for the speedy process is entirely political: to pass a health bill, in whatever form can get a Senate majority, before opposition can mount further. And there could be big consequences for millions of Americans as a result.

The Republicans are still writing major parts of a bill they want to vote on this week

Health policy analysts immediately poured over the Better Care Reconciliation Act shortly after it was posted online last Thursday morning.

Many of us noticed that something key was missing from the 142-page text: any sort of penalty for remaining uninsured. Health policy experts roundly agree that, if you’re going to require health insurers to accept sick patients (as the Senate bill does) then you also need some kind of policy to push healthy people to sign up, too.

This is why the Affordable Care Act had an individual mandate, a penalty levied on those who decide to remain uninsured. This is why the House health care bill would charge people who have a break in coverage 30 percent higher premiums when they reenroll in a new plan.

And this is why it baffled experts across the political spectrum that a similar provision was nowhere to be found in the Senate draft.

My colleague Dylan Scott and I reported over the weekend that the Senate intends to fix this problem, adding in a six-month waiting period for those who fail to maintain continuous coverage. There are different theories floating around Washington about why this was missing from the draft released Thursday — that the language may not have yet been cleared with the Senate parliamentarian or that legislators held it out as a bargaining chip with health plans.

The Senate’s drafting process has left little, if any, space to find policy mess-ups like this one. Large health advocacy groups like the March of Dimes and American Heart Association were reportedly denied meetings with the Senate Majority Leader Mitch McConnell’s office. Democrats were clearly not involved, nor were most Republican senators. There were conspicuously few eyes on the Better Care Act as it was written.

This policy error was easy to spot. It was a big, gaping hole in the health care bill that will be remedied. But there are other, unintended consequences that aren’t quite so apparent — the ones that take weeks of reading to understand.

Case in point: It was 10 days after the House introduced its American Health Care Act that analysts at the Brookings Institution realized that the law would inadvertently bring back lifetime limits on health insurance.

This is an absolutely crucial regulation for Americans who have exceptionally high health care spending, and it took health wonks more than a week to figure out what this new health bill would do to that provision.

Late Sunday night, I broke news about another provision of the Senate bill that has received little attention — reforms to the small business insurance market — and may raise premiums. A health insurance industry source has privately expressed worry that this provision would “leave consumers at risk.”

The consequences of the Senate bill are becoming more clear by the day. The problem is, there just aren’t a lot of days left until the Senate plans to vote — and that means we probably won’t know about many of the consequences lurking inside until we see them unfold as part of a new law.

Barely anyone has discussed or seen the Senate bill

The Senate held 22 hearings in its debate over the Affordable Care Act during the 111th Congress, according to research by Vox’s Garet Williams and Carly Sitrin. This included hearings on everything from what counts as quality health care to how the country’s already stretched workforce would handle absorbing millions more patients.

There have been zero hearings about the Republicans’ Senate bill. There have been zero venues for patients with lifetime limits, for example, to make the case against reviving that policy — or health policy experts to offer testimony on the best ways to incentivize healthy Americans to purchase health coverage.

This isn’t to say Republicans couldn’t have hearings. The Thursday deadline is artificial, set by McConnell to speed the legislating process along. It would only take three Republican senators refusing to vote for a bill without a hearing to force such consideration of the bill.

No senator has made that proposal yet, or said they can’t vote for a bill that only receives one week’s consideration — although some, like Johnson, have edged close.

“I have a hard time believing Wisconsin constituents or even myself will have enough time to properly evaluate this,” Johnson said on Sunday, raising the prospect that he might vote against a motion to begin considering the bill on the Senate floor. “So I’ve been encouraging leadership, the White House, anybody I can talk to for quite some time, let’s not rush this process. Let’s have the integrity to show the American people what it is, show them the truth.”

Or, if nothing else, give them some time to figure out how the bill might actually affect their lives.

Jim Tankersley contributed to this story.