You could almost picture Senate Majority Leader Mitch McConnell (R-Ky.) banging his head against a wall (or at least taking a long swig of Kentucky bourbon) when Trump tweeted this yesterday morning:

Trump was referring to the so-called nuclear option -- a tactic that McConnell could choose to employ that would allow the Senate to pass all legislation with just 51 votes instead of what's become the more customary 60. As the Senate has become more partisan, more and more of the minority party's rights have been eroded -- first, in 2013, when under then-Majority Harry M. Reid (D-Nev.) the chamber moved to allow approval of executive branch and judicial nominations by a simple majority; and again more recently, under McConnell's stewardship, by applying that standard to Supreme Court nominations, once considered untouchable.

AD

AD

But with his policy agenda in trouble in Washington, Trump wants to go even further.

If you’re thinking of just the here and now, dropping the legislative filibuster would give Republicans the best of both worlds. They could repeal and replace the Affordable Care Act without any help from Democrats. And they could do it through the normal legislative process instead of having to maneuver through arcane and limiting rules accompanying the budget bill they’re currently using.

“I think he wants to see action, that’s what he wants,” White House press secretary Sean Spicer said Tuesday when asked about Trump’s tweet. “He wants to see things move through the House and the Senate. He wants people to stop playing games.”

It’s not the first time Trump has suggested going nuclear. In another tweet earlier this month, the president called for action on legislation with 51 votes or else:

And Trump told Fox News in an April 28 interview that “the filibuster concept is not a good concept to start off with ... You’re really forced into doing things that you would normally not do except for these archaic rules," Trump complained.

AD

AD

McConnell has shut down the idea of ditching the legislative filibuster before. And he again rejected the idea yesterday, real fast, when his office responded to Trump by noting that Republicans can already pass health care with a 51-vote majority by using the budget process.

“Senator McConnell agrees that both health care and tax reform are essential and that is why Republicans in Congress are using the reconciliation process to prevent a partisan filibuster of these two critical legislative agenda items,” said McConnell spokeswoman Antonia Ferrier in response to Trump's tweet.

Why is McConnell dead-set against widening his own party’s unilateral ability to pass legislation? Because he knows it would hurt Republicans in the long-term. And it wouldn’t help them that much in passing a health-care bill now.

AD

AD

To state the obvious, at some point Democrats will probably regain control of the Senate. But the reasons that McConnell is resisting go deeper than that. Many conservative thinkers feel that doing away with the legislative filibuster would benefit Democrats more than Republicans. That’s because progressives are generally more interested in passing new government programs whereas conservatives are hesitant to broaden the government's role in just about anything. And the GOP is finding that eliminating government programs -- especially entitlements -- is no simple task, even when they're in the majority.

“Ending the filibuster would make the consequences of any future Democratic victories much more punishing for conservatives — and Republicans have never proven the ability to significantly roll back expansions of the welfare state that took place when Democrats were in power,” the Washington Examiner’s Phil Klein wrote back in 2015.

It would become much easier for Democrats to enact their priorities if they needed only 51 Senate votes. But Republicans probably wouldn’t have equal ease in rolling back their own wish list. Just look at how they’re struggling to pull back on the ACA now that millions of Americans have federally-subsidized insurance plans because of it.

AD

AD

Trump didn’t just show a lack of foresight with his tweet. He also demonstrated he doesn’t fully understand just how hard it is for Senate Republicans to agree among themselves on a health-care bill. The GOP has already given itself a simple-majority threshold by using budget reconciliation. And the party is still in real danger of hitting an impassable roadblock of its own making when lawmakers return to town after the Memorial Day recess. There are plenty of ideological differences on health care within the 52-vote Senate GOP conference itself.

“At the end of the day, we have the power of 51 and are struggling so it seems like a false choice,” a former Senate GOP staffer told me.

Nearly every senator – even many who most want to ditch the ACA -- seems to feel that abolishing the legislative filibuster would be foolhardy. Senate Finance Committee Chair Orrin G. Hatch (R-Utah) has said he would get Trump “back in line” on the issue. Even Sen. Mike Lee (R-Utah) sides with McConnell on the matter. “We want to keep the current Senate rules,” a Lee spokesman told The Health 202.

AD

AD

The outlier may be Sen. Ted Cruz (R-Texas). A spokesman pointed to comments the Texas senator made back in April when he indicated he could be open in the future to “going nuclear” on legislation but wanted to “wait and see how the facts develop.”

“At this point, there is not a majority for ending the legislative filibuster,” Cruz said on April 6. “My hope is that Democrats will stop their unreasonable across-the-board obstruction and allow the Senate to operate. If they continue an unmovable blockade, I suspect the votes will shift on that question as well.”

But there may be enough health-care explosions on Capitol Hill without Republicans going nuclear too.

AD

AHH, OOF and OUCH

AHH: Trump's appointee to lead the agency overseeing Medicare, Medicaid and Obamacare said Tuesday that the GOP health-care bill is "outdated" and what's more important is legislation in the Senate, when asked to respond to the CBO's projection that it would cost 23 million people their health insurance. Seema Verma, administrator of the Centers for Medicare and Medicaid Services, also raised questions about the CBO's ability to accurately score the bill, the Washington Examiner's Kimberly Leonard reports.

AD

"We disagree with some of the premises that they are indicating in this report," Verma said, speaking to USA Today in a live-streamed interview.

OOF: Police arrested 32 people yesterday in North Carolina's legislative building for holding a sit-in to protest Republican lawmakers' refusal to accept the ACA's Medicaid expansion. Among them was North Carolina NAACP leader William Barber, a leader in the protests, which have resulted in 1,000 arrests since 2013. The protesters, who face charges of second-degree trespassing, were arrested after marching through hallways to the offices of legislative leaders and sitting outside them.

AD

OUCH: The ousted executive of Molina Healthcare is blaming premium hikes under Obamacare not on faults in the law itself, but on Republicans and their efforts to sabotage it. In a U.S. News and World Report piece, J. Mario Molina blasts Republicans for their narrative that the health-care law is in a "death spiral" that will inevitably "explode."

AD

"That narrative is patently false," Molina writes. "In fact, most of the instability driving up premiums in the marketplace can be directly traced to Republicans' efforts to undermine the health care law for their own political purposes."

Until he was fired a few weeks ago, Molina was CEO of the health-insurance company, which had invested heavily in the state marketplaces but suffered deep and unexpected losses last year. While the company has said Molina was let go over disappointing financial performance, Molina has suggested it's partly because of his public statements about the health-care law.

HEALTH ON THE HILL

--Congress is on recess all week, but the word on the street is that Senate staffers are busy crafting legislative text of a health-care bill so senators have something to consider when they return to town next week.

AD

AD

They better be working fast because Trump faces "an increasingly narrow path to achieve major legislative victories before the looming August recess, with only two months left to revive his health-care or tax initiatives before Congress departs for a long break," the Post's Damian Paletta and Mike DeBonis report. "White House officials plan to push Senate Republicans in June to vote on a repeal of the Affordable Care Act, and they want to spend the rest of the summer whipping up support for major tax cuts."

But there's a lot that could get in the way. "Congress also faces an increasing number of legislative distractions that could further imperil Trump’s agenda," my colleagues write. "There is a big divide among Republicans over whether they can vote to pass a budget resolution in the coming months, and failing to do so could make it much more difficult to change the tax code. In addition, White House officials are now demanding that Congress vote to raise the debt ceiling before the August break — pressing members to take a difficult vote before they head back to their districts."

In the meantime, insurers are trying to get a word in edgewise. They want the GOP health legislation to contain adequate funding for Medicaid, repeal all of the ACA's taxes and base subsidies on income, not just age, according to letters sent to Hatch.

The influential insurer association, America's Health Insurance Plans, especially urged that a GOP plan include immediate steps to stabilize the individual market that "faces immediate and significant challenges, especially for the 2018 plan year." AHIP blamed the problems partly on "structural issues and policy decisions" made in the early years of ACA implementation and partly on uncertainty from Trump's indecision on whether to keep funding extra cost-sharing subsidies. They are also concerned about the likelihood that the administration won't enforce the individual mandate.

UnitedHealth Group, which pulled out of AHIP a few years ago, was even more critical of the Obamacare marketplaces. The major insurer wants them disbanded entirely beginning in 2019 and oversight of the individual market returned to states, according to a letter to Hatch obtained by The Health 202. UnitedHealth also wrote that Congress should eliminate the ACA's essential health benefits and its metallic actuarial value-rating system, allow insurers to charge older people five times more than younger people instead of just three times and restore the ability of insurers to sell short-term and limited coverage policies.

Getting rid of the ACA's Health Insurance Tax (called HIT) is a biggie for UnitedHealth. The insurer says it is pricing the tax into 2018 policies, arguing that it will cause annual premiums to rise by $210 for small employers and $530 for families buying coverage on their own. "Full repeal of the Health Insurance Tax (HIT) is one of the quickest and easiest ways to lower health care costs, prevent further disruption, and ensure market stability," the insurer wrote.

--Watch out if you happen to be Reps. Todd Rokita (Ind.), Luke Messer (Ind.), Lou Barletta (Pa.), Evan Jenkins W.Va.), Alex Mooney (W.Va.), Kevin Cramer (N.D.), Vicky Hartzler (Mo.) or Ann Wagner (Mo.). These Republican representatives running for Senate seats, or at least eyeing them, are top targets of the Democratic Senatorial Campaign Committee, according to a memo the DSCC is releasing today. The memo also names Sens. Jeff Flake of Arizona and Dean Heller of Nevada, both facing tough reelection battles next year.

Here's how the DSCC plans to attack these Republicans, who have either voted for the ACHA or expressed support for it. Its topline messages include this messaging on health care:

1. Republicans will raise out-of-pocket costs with higher premiums, deductibles, and the cost of prescription drugs.

2. People with preexisting conditions will lose protection and can lose coverage.

3. Republicans impose an age tax on older Americans, forcing them to pay premiums as much as five times higher than what others pay.

Meanwhile, some lawmakers held town halls -- or were afraid to? -- in their states and districts, where health care was inevitably a topic:

From GOP congressman Darrell Issa's Democratic foe in California in 2018:

Issa pushed back:

CHART CHECKER

--A new poll confirms the GOP health-care plan is pretty unpopular, even when compared to Obamacare, which itself hasn't always enjoyed the public's smile. A new Kaiser Family Foundation poll finds that just 31 percent of Americans hold favorable views of the ACHA, while 49 percent view the ACA favorably. And as the Senate considers its own version of a bill overhauling the ACA, a majority of the public wants the upper chamber to either make major changes to the House bill or not pass it all. Fewer want the Senate to pass the bill with only minor changes or in its current form.

Here are the survey's three most interesting takeaways:

1. For both the ACA and the GOP bill, the poll found a deep, partisan divide in how respondents felt about them. Democrats favor the ACA over Republicans by a 6.5 to 1 ratio, while Republicans favor the AHCA over Democrats by a ratio of 8.3 to 1.

2. Many more people are blaming President Trump and Republicans in Congress than Democrats for problems with the ACA moving forward. Sixty-three percent said it's Republicans' fault if the ACA continues to have problems, more than twice the share who say President Obama and Democrats are responsible.

3. The four top elements Republicans want in a health-care bill are: Allowing states to have Medicaid work requirements; providing funding for state high-risk pools; changing Medicaid funding to a block-grant system and stopping federal Medicaid payments to Planned Parenthood.

Here are some more interesting reads about Capitol Hill and beyond:

Here are some more good reads about how health care is playing during recess:

DAYBOOK

Today

More senators and representatives will hold town halls tonight, where health-care is bound to be a pointed topic of debate. One of those senators is Bill Cassidy (R-La.), who’s considered a crucial vote in the Senate’s efforts to repeal and replace Obamacare. (Cassidy held a separate town hall yesterday, and the focus quickly shifted from the set agenda to health-care.)

Coming up

Congress will reconvene next week, and, as a reminder, Senate Republicans hope to have at least a “partial health-care draft” when they return.

SUGAR RUSH

Do you know what "covfefe" means? We sure don't. Trump tweeted out this early this morning: "Despite the constant negative press covfefe..." Then erased it. Then tweeted the below. Internet memes abound.

Watch Sen. Bernie Sanders blame "oligarchs" for attempts to change the Affordable Care Act: