Last night’s healthcare news

Just a few things in the swirl of chaos that I was aware of but did not have the time nor the inclination to write about as the news was breaking:

1) Seema Verma and CSR in the LA Times
2) The Senate has not received the ACHA yet
3) Defending Joe Lieberman
4) Senator McCaskill’s bare county bill

Let’s look at these four things below the fold as it is a wall of wonky text:

1) Seema Verma reportedly/allegedly offered to fund Cost Sharing Reduction Subsidies to insurers if they backed the AHCA according to LA Times reporting:

At one recent meeting, Seema Verma, whom Trump picked to oversee the federal Medicare and Medicaid programs, stunned insurance industry officials by suggesting a bargain: The administration would fund the CSRs if insurers supported the House Republican bill to repeal the Affordable Care Act.

“It made no sense,” said one official at the meeting…

Trump administration officials denied Verma suggested the administration would fund the CSRs.

I am curious about a few things on this alleged offer.

  • Are there contemporaneous notes/memos/summaries of the meeting and alleged offer in the files of multiple insurers?
  • Has the HHS Inspector General been made aware of this allegation?
  • If this offer was made why did Verma think it was a good deal?
  • That last point is purely a cynical point. The AHCA takes out ~$850 billion dollars from Medicaid over ten years. Over 70% of Medicaid is administered by private insurers. Medicaid managed care is profitable. Medicaid managed care is fairly predictable. A decent MCO should make 2% to 4% a year on this line of business. Exchange is much smaller than Medicaid managed care. Cost Sharing Reduction subsidies is an even smaller of the individual market revenue pool. So the deal is take a small pool of money for a still uncertain line of business in exchange for supporting very significant cuts to a steady, profitable business segment. Why is this a plausible deal?

    2) AHCA still has not been transmitted to the Senate according to Bloomberg.

    There are several issues going on with the AHCA that are reconciliation rule related. First it needs a Congressional Budget Office (CBO) score. That should come next week. The CBO score needs to show that the bill fulfills reconciliation instructions. Those instructions are that the bill must save at least $1 billion dollars over ten years from two Senate committees; Health, Education, Labor and Pensions (HELP) and Senate Finance. This is the $2 billion dollars that Matt Fuller references. Secondly, the CBO must show that there are savings in the years after the close of the budget window.

    The big question is how will the CBO model the uptake of the MacArthur waivers. If they model that very few states use them, then the score will work. If the CBO models the waivers will be broadly used and this leads to a lot of people to use waivers to buy very skimpy plans then the budget cushion from the first version of the AHCA get eaten up very quickly. Jed Graham noticed this in March:

    the GOP bill would mostly retain ObamaCare coverage rules, insurance would be unaffordable for lower-income and older adults with the new, smaller tax credits on offer, so some 30 million people wouldn’t claim the GOP tax credit averaging $3,000 in 2020 and rising with inflation. That would add up to more than $600 billion in unclaimed subsidies through 2026, or roughly the same $600 billion amount by which House Speaker Paul Ryan’s plan cuts taxes. Those unspent subsidies go a long way to explaining why CBO found that the American Health Care Act would reduce deficits by $323 billion over a decade.

    Every additional person who is insured because the premiums for the healthy are cheaper makes the CBO score worse. If five million more people at an average subsidy of $3,000 per year buy insurance because of the MacArthur waiver, the ten year increased spending on age based subsidies basically wipes out the deficit reduction. At that point the House Republican options are to let the bill die, reduce subsidies or delay/decrease the tax cuts.

    We don’t know how the CBO will score this bill nor how they will model the MacArthur amendment.

    The other major reconciliation landmine that is being probed for now is the committee of jurisdiction problem. Chris Jacobs, a conservative procedural expert explains:

    violations of the third (material outside the jurisdiction of committees charged with reporting reconciliation legislation) and sixth (changes to Title II of the Social Security Act) tests are fatal to the entire bill.

    Given that the AHCA was put together on an ad-hoc basis, a very thorough review of the bill for committee of jurisdiction problems is probably ongoing.

    If there is either a bad CBO score on one of three fiscal grounds (insufficient savings to HELP, insufficient savings to Finance, deficit increases in out years) or a reconciliation committee of jurisdiction problem identified, the bill dies in the Senate if the Senate has received it. The reconciliation instruction for the fiscal year would be burned. So by not submitted the bill for consideration in the Senate, the House is keeping its options open.

    I have no ability to evaluate the probability of either a CBO or a reconciliation problem. My guess is the combined probabilities leading to new vote in the House is very low but non-zero.

    3) Defending Joe Lieberman

    The version of the public option that was plausible was one which was not tied to Medicare rates. Instead it would need to negotiate with providers. If it was backed with significant federal funding to cover operational losses in the first few years, it would solve one significant problem. It would be a solution to the no insurer in a county problem. It would still be at risk due to morbidity concerns that we talked about yesterday, it would still be at risk due to CSR worries. It’s premiums would also be tracking the same general direction and level as the premium increase requests that we are already seeing.

    4) Senator McCaskill’s DC Exchange bill for no insurer counties

    She is introducing a bill that would allow people who live in counties without an on-Exchange insurer to use the Washington DC SHOP exchange to buy coverage.

    McCaskill’s legislation would allow individuals in “bare counties”—counties with no insurers participating in the individual insurance marketplaces—access to the same insurance plans offered to members of Congress and Congressional staff….

    This is great politics. It sounds like a viable solution. And if this was signed into law in December 2016 or January 2017 it might work. The Washington DC SHOP exchange is where Congress and their staffers can use their Federal Employee Health Plan employer contribution as a subsidy to buy a subsidized health care plan. Since Capitol Hill employs lots of people who live all over the country, the SHOP plans tend to have fairly broad (and expensive) national networks.

    This is not a viable solution for 2018.

    The insurers that are prepping their rates for SHOP at this time are basing their rates on insuring small business in Washington DC plus Congress and their staff. That is a predictable risk pool that they know. This proposal is a massive curve ball to their projections and their products. They might have to cover 50,000 lives in Tennessee; they won’t know that until after every insurer in Tennessee files and makes a firm commitment. They might have to cover 100,000 lives in Texas. They won’t know that until September. They might have to cover a single county in Alaska. They won’t know until September.

    If I was an actuary working for an insurer that is on the DC SHOP exchange and I saw this proposal, I would immediately find a pint of Ben and Jerry’s, go to the corner, curl up in a ball and eat my fear away.

    This sounds like a good idea. It is a simple, elegant and wrong solution to a real problem.

35 replies
  1. 1

    Gigantic thanks for this. I’m disappointed, but at least I have the expert’s opinion. #2 is the biggest news you can get.

  2. 2
    Baud says:

    Wasn’t the last CBO score done on the fly? Maybe now they’ve had tine to do a more careful analysis, they will have better estimates. Fingers crossed.

  3. 3
    Chyron HR says:

    It baffles me that people are still relitigating the ACA. Voters willingly and/or cluelessly handed control of the government over to the party that wants to destroy any health-care reform, regardless of how popular the bill was or how unpopular repeal is. Would we somehow be better off if they were killing Medicare-for-All along with Medicaid?

  4. 4
    Morzer says:

    My guess is that the Liebertross pick will backfire on Trump pretty quickly if he’s silly enough to go through with it. Liebertross has a colossal vanity, no relevant experience and is a Beltway antique. If the FBI decide to give him the run around, it’ll be extremely easy for them.

  5. 5

    @Chyron HR:
    I know some Unreconstructed Sanderites, and have plenty of experience with them here. They live in an alternate world where Democrats hate the poor and only they care about minorities(?!). How can you communicate with that?

  6. 6
    hellslittlestangel says:

    Because she’s somewhat conservative, McCaskill doesn’t get enough credit for being a good politician, a good Democrat, and a good human being.

  7. 7
    Morzer says:


    You don’t. As with the Trump voters, you leave them alone, you look at the yuuuge, classy pool of people who didn’t vote this time around and you figure out a way to get to a slice of them instead. Much more meat on that bone.

  8. 8
    jacy says:

    Floating Lieberman’s name gave me a giant WTF. He’s despised from lots of angles. He doesn’t have relevant experience to head the FBI in any way, shape, or form. He’s 75. He’s annoying as fuck. He’s yesterday’s fishwrapper and totally irrelevant except as a footnote for all the stupid, self-serving shit he pulled. Where is the angle that even makes this remotely a good idea, even if you’re a moron? I just don’t get it.

  9. 9
    Morzer says:


    It’s Trump trying to be the troll-in-chief, possibly urged on by a deluded “strategist” who believes that Liebertross is a Democrat, so this will win over Democrats and be bipartisany and so forth.

  10. 10
    MomSense says:


    I missed you the other day. Just wanted to say that I hope you feel better.

  11. 11
    Cheryl Rofer says:

    On point 1, it’s remarkable that this administration can’t understand that other people and organizations have their own interests and can’t be bought off. Or, more cynically, that the price of buying off must be negotiated.

  12. 12
    Baud says:


    possibly urged on by a deluded “strategist” who believes that Liebertross is a Democrat

    I hear that the Connecticut for Lieberman party is 100% behind this move.

  13. 13
    mb says:

    RE: defending Lieberman — You should save your breath. Fucking over the mcare option was not Lieberman’s original sin. IMO, the only silver lining in the 2000 shiticane of an election was that Joe Lieberman never got anywhere close to the oval office.

  14. 14
    Morzer says:


    I favor the Disconnect&cut Lieberman party.

  15. 15
    jacy says:


    I’m lots better. They put me on synthetic thyroid — I don’t know how much is just placebo effect from the knowledge they’ve given me something, but two days worth has made a lot of my physical symptoms and mental fog better. Hopefully in a week or two there’ll be vast improvement. And getting two nights worth of uninterrupted sleep after a month of 2-3 hours afternoon sleep a day is probably a good thing. :) My doc prescribed Restoril for the insomnia and so far it’s working well without the nasty side-effects I’ve sometimes had on benzos.

  16. 16
    Morzer says:

    Bess Kalb‏Verified account @bessbell 21h21 hours ago
    Everyone, show some respect. Roger Ailes had a family. And a family. And a family. And a family. And a family. And a family. And a family.

  17. 17
    mouse tolliver says:

    @jacy: BriWi and Nicole Wallace loved the Lieberman pick. He’s one of the Three Amigos!

    McCaskill’s on record saying she’d vote no on putting Lieberman in charge of the FBI. And Kelly O’Donnell reported that other Democrats were saying they wouldn’t support him either.

    Lieberman is a member of an education group funded by Betsy Devos. He even went to her confirmation hearing to publicly support her nomination. And he works for the law firm that represents Trump and Bill O’Reilly. Independent my ass!

  18. 18
    TomatoQueen says:

    Joe Lieberman used to be my Senator. Conscience of the Senate my Yankee backside. Ptui.

  19. 19
    gvg says:

    Has Leiberman actually said he wants this job? I haven’t read anything that quoted him or mentioned they had spoken to him. It strikes me a possible that Trumps idiots would just assume something.
    Are other republicans besides Trumps loudest supporters supporting this idea? I wouldn’t think they would like it too. On the bright side, Trump can probably make an enemy of Leiberman or almost any pick, pretty fast. It would be nice if he got into a feud with Sessions.

  20. 20
    jacy says:


    Has Leiberman every not wanted anything that would put his grandstanding ass in front of a camera? I think not.

    @mouse tolliver:

    Shit, if they’re for it, you know it’s a horrible idea.

    I don’t see him getting through the senate. No law enforcement cred should be the Senate’s get out of jail free card. Besides, who knows what horrors are going to transpire on Trump’s world tour. Nine days for him to turn the planet into a smoking crater, where Joe-Fucking-Leiberman is the least of anybody’s problems.

  21. 21
    Morzer says:


    Has Leiberman actually said he wants this job?

    He’s a fatuous, posturing egomaniac offered a job with genuine power and huge self-publicizing potential. What would your bet be?

  22. 22
    Bobby Thomson says:

    So the deal is take a small pool of money for a still uncertain line of business in exchange for supporting very significant cuts to a steady, profitable business segment. Why is this a plausible deal?

    Forget it, Jake. It’s Trump.

  23. 23
    gvg says:

    @Morzer: Working for a moron who has an even bigger ego? Is Lieberman stupid enough? Seems to me the Trump ship doesn’t look that attractive to ambitious smart people.

    I just think it’s curious I haven’t seen any actual interviews or quotes from Lieberman, especially if his presumed motive is liking attention.

  24. 24
    Morzer says:


    Well, until very recently Liebertross was massively irrelevant, so I doubt people wanted to waste time on him. Which, come to think of it, makes it more likely that he’ll gallop forward into the limelight.

  25. 25

    @mb: There are many reasons to hate on Lieberman — Medicare buy-in to age 55 is the health policy related one. Please see one of my first posts at Balloon-Juice: (also note, I donated to Ned Lamont in 2006)

    But my bigger point is that the public option would not be a solution to the problem insurers are facing right now. It is not sabotage proof.

  26. 26
    mere mortal says:

    “I would immediately find a pint of Ben and Jerry’s, go to the corner, curl up in a ball and eat my fear away.”

    This seems like a fine plan, and there’s plenty of Ben and Jerry’s. However, all the corners are currently occupied by other folks with their own fears, eating away. There’s still some space on the couch. Did you ever hear the story about why the Office was Oval?

    Also, fuck Joe Lieberman.

  27. 27
    Villago Delenda Est says:

    Lieberman, sanctimonious prick. Can’t be tossed under a bus by anyone at all too soon.

  28. 28

    Yet another example of a person who wears his religion on his sleeve but is an all around nasty prick.

  29. 29
    Mnemosyne says:

    @David Anderson:

    I think the main reason the Lieberman thing came up in regards to health care is that there’s a myth on the left that Obama personally killed the proposals for both the public option and Medicare buy-in, while those of us who were paying attention at the time remember full well that Lieberman was the asshole who killed both. Thanks for the link to your 2013 post for the next time we have to point out that lefty dudebros are not only stupid, they’re also wrong.

  30. 30
    James Powell says:


    How can you communicate with that?

    You cannot appeal to a mind that believes being closed to certain ideas is a matter of personal identity. Just as the Trump voters believe that African Americans and immigrants are living large off of the taxpayers while whites suffer the indignities of poverty, the Nader/Sanders/Whoever people believe that the only barrier to socialist paradise is Democratic Party corruption.

    I really can’t stand those people. Talking to them about anything is a waste of time.

  31. 31
    smintheus says:

    Lieberman blocked the opening of Medicare to the 55 to 64 age range. He’s responsible for the danger those people now face of losing health insurance under Trumpcare. There’s no way the Republicans would have dared to take away Medicare availability once it had been granted.

  32. 32
    AnneWith says:

    @jacy: I’ve been referring to him on teh Twitterz as Fucking Joe Fucking Lieberman, because he is that big of a douchebag.

  33. 33
    lowtechcyclist says:

    @mouse tolliver:

    Lieberman is a member of an education group funded by Betsy Devos. He even went to her confirmation hearing to publicly support her nomination.

    Guess that answers the Lieberman version of “Kid, have you rehabilitated yourself?” Quite the opposite – he’s become a far bigger shitheel than he was back in the day, and that’s no small feat.

  34. 34
    MomSense says:


    So glad you are feeling better!

  35. 35
    J R in WV says:



    Restoril Uses, Dosage & Side Effects – › Conditions › Insomnia
    Restoril (temazepam) is a benzodiazepine (ben-zoe-dye-AZE-eh-peen). Temazepam affects chemicals in the brain that may be unbalanced in people with sleep problems (insomnia). Restoril is used to treat insomnia symptoms, such as trouble falling asleep or staying asleep.

    It does work well, but it stopped working for me after a while. Ambien may be a better choice, although they all have side effects. Sleep is important, though!

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