Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) on Thursday formally introduced their proposal to shore up the Affordable Care Act’s private insurance markets. And in a show of the proposal’s bipartisan strength, they announced the bill now has 24 sponsors, with precisely 12 from each party.

It will take that kind of support to push the proposal through Congress, given many Republicans’ feelings about anything related to “Obamacare,” not to mention the contradictory statements President Donald Trump has made lately. But both Alexander and Murray are acting like their proposal could still become law at some point and there is good reason to think they are right.

The bill, which emerged from hearings and negotiations that Alexander and Murray convened over the course of the past few weeks, would restore several billion dollars’ worth of subsidies to insurers that Trump cut off last week. In addition, it would appropriate about $100 million in funding for enrollment and outreach ― again, effectively replacing money that Trump took away.

At the same time, the bill would allow insurers to sell catastrophic policies, with extremely high out-of-pocket expenses in exchange for lower premiums, to consumers of all ages ― rather than only to consumers who are younger than 30, as the law currently allows. The bill would also make it easier for states to tweak some of the Affordable Care Act’s regulations.


None of the changes the bill contemplates are particularly dramatic. It’s really a series of small wins and concessions for each side, in the hopes of keeping coverage more affordable and available at least for the next few years ― at a time when, for reasons that reflect both the Affordable Care Act’s design and recent management of it, consumers in many states are facing higher prices and dwindling choices.

It’s precisely the kind of bill both Alexander and Murray had said they wanted to write. In successive remarks from the Senate floor, the two senators ― one the Senate Health, Education, Labor and Pensions Committee chairman, the other the committee’s ranking Democratic member ― praised each other for diligence and an open mind.

“It sends a powerful message that when members of Congress decide to get past the talking points and take just a few steps out of partisan corner, there’s really a lot we can agree on ― and a lot we can get done,” Murray said.

But it’s been years since such bipartisanship was typical, particularly on the polarizing issue of health care. Many Republicans refuse to even consider supporting legislation that might bolster ― or be seen to bolster ― a law they have spent seven-plus years vowing to rip out, root and branch.

And then there is Trump, who has sent so many wildly inconsistent signals it’s difficult to keep track of them. In just the past few days, he seemed to change his mind on multiple occasions ― at various points praising the Alexander-Murray plan publicly, only to announce, in some cases hours later, that he could never back a bill that includes a “bailout” of insurance companies.

In his floor remarks, Alexander addressed the bailout argument directly. He pointed out that the payments Trump cut off, known as cost-sharing reductions or CSRs, merely reimburse insurers for special low-deductible policies that they must, by law, offer to poor and some middle-class consumers. Alexander went on to say that the bill includes a whole section on making sure a restoration of the CSRs ends up benefiting consumers, not insurers.

“The president says there should be no bailout of insurance companies,” Alexander said. “I agree 100 percent.”

Alexander also told his fellow Republicans that endorsing his bill was not tantamount to giving up on repeal. As proof, he noted that among the GOP co-sponsors are Sens. Bill Cassidy (R-La.) and Lindsey Graham (R-S.C.), who have pledged to keep working on the repeal package they tried but failed to get through the Senate in September.

Besides, Alexander said, holding out for full repeal hasn’t worked so well for Republicans so far.

“Someone said that this bill is not enough,” Alexander said. “Well, it’s more than we’ve gotten for eight years and it’s the first step.”

Both Alexander and Murray spoke about the bill as if it could offer immediate relief on premiums. In reality, insurers and state regulators have already settled on rates for next year and in most cases they have done so in ways that will shield the majority of consumers from the immediate effects of Trump’s cutoff.

That’s largely because other forms of financial assistance will automatically be increased to compensate for cuts in the insurer subsidies. One ironic result is that the federal government will end up spending more money, not less, unless and until the federal government restores the insurer subsidies ― a point Alexander noted in his appeal to fellow Republicans.

But if Alexander-Murray becomes law and the subsidies start flowing again, the proposal envisions insurers paying back any extra money they receive, through rebates to consumers or the federal government or both. 

In addition, passing the bill could have a profound effect on the mentality of insurers, who will begin planning for 2019 sometime in the next few months. If the carriers know the federal government has restored the payments and is investing in outreach ― and, more important, if they see Congress acting to bolster insurance markets where they are weak ― they are more likely to continue offering policies.

That still makes it a hard sell, particularly among conservative Republicans. On Wednesday, the office of House Speaker Paul Ryan (R-Wis.) released an official statement saying nothing in the Alexander-Murray proposal alters Ryan’s “view that the Senate should keep its focus on repeal and replace of Obamacare.” Some Republicans are already talking about modifying the proposal in ways that could make it toxic for Democrats.

But particularly if Republicans worry they will take the blame for rising premiums this year ― a very real possibility, given that polls show most Americans now hold Republicans responsible for management of the health care system ― GOP leaders could pass the Alexander-Murray proposal, or something like it, by attaching it to larger, must-pass legislation. The spending bill that Congress will have to approve in December, in order to keep the government running, is the obvious candidate for this.

That makes the bill’s show of support important ― particularly because it represents not just both parties but also different factions within the parties. Among the co-sponsors are mainstream conservatives such as Sens. Richard Burr (R-N.C.), Johnny Isakson (R-Ga.) and Mike Rounds (R-S.D.), as well as relative moderates like Susan Collins (R-Maine), John McCain (R-Ariz.) and Lisa Murkowski (R-Alaska).

The co-sponsors from the Democratic caucus include members representing a similarly wide ideological spectrum ― with relatively liberal senators, like Tammy Baldwin (D-Wis.) and Al Franken (D-Minn.), along with relative moderates such as Heidi Heitkamp (D-N.D.), Angus King (I-Maine) and Joe Manchin (D-W.Va.).

Alexander and Murray are also drawing support from beyond Capitol Hill. A bipartisan group of 10 governors, including three Republicans and one Republican-turned-independent, on Wednesday issued a letter supporting the proposal. Also on board are a wide array of health care organizations ― all of whom, like most of those governors, had strongly opposed repeal legislation when it came up earlier this year.

Perhaps the most interesting comments of the day actually came from one of those Republican co-sponsors: Murkowski, who spoke immediately after Alexander and Murray and praised the pair for their cooperation. “It’s not only good from a policy perspective,” she said, “it’s good from the perspective of the health of our institution.” 

Back in July, Murkowski was one of three Republicans to vote against repeal legislation the Senate was considering, thereby preventing its passage. One of her big objections was the process that led to the vote ― a rush to craft a bill without formal hearings or deliberation, or any serious attempt to win bipartisan support.

On Thursday, Murkowski didn’t say explicitly that she viewed the Alexander-Murray proposal as a better way to legislate. But the point was clear enough.

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