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Defector of the Day: Sen. Rand Paul

Each day leading up to the Senate vote, we'll take a closer look at a Republican senator who seems to be on the fence on the Better Care Reconciliation Act, what they want, and what role they're likely to play in the debate. Today we focus on Kentucky's most famous ophthalmologist, none other than Sen. Rand Paul.

Sen. Paul has made it clear he is no fan of the Senate health care bill. He has constantly criticized it for keeping too much of the Affordable Care Act intact. Today, though, he issued a clear list of demands:

Expand the role of association health plans. As I reported this weekend, there is a little-noticed provision in the Senate bill that would allow small businesses to purchase skimpier health plans with fewer benefit mandates. Paul wants individuals to be able to buy into those health plans, too. Under his proposal, individuals would be able to join up with small businesses to form an association for purchasing coverage. They would have more bargaining power as a large group and be able to demand low premiums if the individuals and small-business employees involved were young and healthy. But this could be a raw deal for sicker Americans, who may not be able to join up with these associations and would face higher premiums as a result.

As I reported this weekend, there is a little-noticed provision in the Senate bill that would allow small businesses to purchase skimpier health plans with fewer benefit mandates. Paul wants individuals to be able to buy into those health plans, too. Under his proposal, individuals would be able to join up with small businesses to form an association for purchasing coverage. They would have more bargaining power as a large group and be able to demand low premiums if the individuals and small-business employees involved were young and healthy. But this could be a raw deal for sicker Americans, who may not be able to join up with these associations and would face higher premiums as a result. Kill off the law's short-term stability fund for Obamacare. Paul doesn't like the funding being put toward keeping the health law running in 2018 and 2019, before the Senate bill would transition to the new system. This includes the funding of cost-sharing reduction subsidies for low-income ACA enrollees.

Paul doesn't like the funding being put toward keeping the health law running in 2018 and 2019, before the Senate bill would transition to the new system. This includes the funding of cost-sharing reduction subsidies for low-income ACA enrollees. End the premium tax credits — or at least don't make them advanceable and refundable. Right now, the ACA tax credits are paid on a monthly basis (rather than a lump sum as part of an annual tax refund) and go well beyond offsetting the taxes that Americans owe the government. Paul doesn't like that much at all. He doesn't like how this builds a new entitlement program, and would like to see these tax credits become non-advanceable and nonrefundable. This would have the practical effect of putting coverage financially out of reach of many who rely on this part of the law.

Right now, the ACA tax credits are paid on a monthly basis (rather than a lump sum as part of an annual tax refund) and go well beyond offsetting the taxes that Americans owe the government. Paul doesn't like that much at all. He doesn't like how this builds a new entitlement program, and would like to see these tax credits become non-advanceable and nonrefundable. This would have the practical effect of putting coverage financially out of reach of many who rely on this part of the law. Get rid of the waiting period. The Senate leadership on Monday added a six-month waiting period for those who want to join the individual market and have had a lapse in coverage at some point in the past year. "This continues the top-down approach that has led to increased premiums and has not changed behavior of the young and healthy who are priced out of the market, and those who game the system to purchase insurance after they become sick," Paul writes.

What will get him on board: Some version of these demands, probably. It's instructive to look at how the Freedom Caucus negotiations worked. That group started with a long list of demands but ultimately whittled down the list to two nonnegotiable proposals. So it's possible we'll see Paul settle for a few of these ideas rather than his entire list.

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Chart of the Day

Alabama would see biggest premium spikes under Senate bill. Check out the full slideshow presentation from the Kaiser Family Foundation, which compares how premiums would change under the Better Care Reconciliation Act.

Kliff’s Notes

Your daily top health care reads, with research help from Caitlin Davis

Today's top news

"Trump, Senate leaders attempt to regroup after postponing vote to overhaul Obamacare" : "Just how realistic a vote is after July 4 remains unclear. At least one senator who had publicly opposed the procedural vote McConnell had hoped to take Tuesday — Dean Heller (Nev.) — indicated that he was willing to reconsider his initial opposition, if the bill was going to be reworked." —Sean Sullivan, Kelsey Snell, and Juliet Eilperin, Washington Post

"Just how realistic a vote is after July 4 remains unclear. At least one senator who had publicly opposed the procedural vote McConnell had hoped to take Tuesday — Dean Heller (Nev.) — indicated that he was willing to reconsider his initial opposition, if the bill was going to be reworked." —Sean Sullivan, Kelsey Snell, and Juliet Eilperin, Washington Post " Calif. Officials Sound Alarm, Envisioning $114B Hit To Medi-Cal Under U.S. Senate Bill" : "California risks losing $114.6 billion in federal funds within a decade for its Medicaid program under the Senate health care bill, a decline that would require the state to completely dismantle and rebuild the public insurance program that now serves one-third of the state, health leaders said Wednesday." —Anna Gorman, Kaiser Health News

"California risks losing $114.6 billion in federal funds within a decade for its Medicaid program under the Senate health care bill, a decline that would require the state to completely dismantle and rebuild the public insurance program that now serves one-third of the state, health leaders said Wednesday." —Anna Gorman, Kaiser Health News "Trump: will be 'very tough' to pass health bill": "President Trump touched on health care during an energy roundtable Wednesday, saying he'd had a 'tremendous meeting' yesterday with Republican senators, and that although the Senate bill will be 'very tough' to get approved, he thinks the GOP will 'get at least very close' to passing it, and will ultimately get it over the line." —Alayna Treene, Axios

Analysis and longer reads

" Health Bill Draws Fiscal Fault Line Between Old and Poor—and the Poor Are Losing" : “The health-care overhaul that Senate leaders floated this past week does more than roll back an entitlement Republicans have loathed since the day it was enacted in 2010. It portends a deeper struggle over the safety net that pits the elderly against the poor.” —Greg Ip, Wall Street Journal

“The health-care overhaul that Senate leaders floated this past week does more than roll back an entitlement Republicans have loathed since the day it was enacted in 2010. It portends a deeper struggle over the safety net that pits the elderly against the poor.” —Greg Ip, Wall Street Journal "On Senate Health Bill, Trump Falters in the Closer’s Role" : “Mr. Trump and his staff played a critical role in persuading House Republicans to pass health care legislation in May, with the president personally calling dozens of wavering House members. But the Trump team’s heavy-handed tactics have been ineffective in the Senate, and White House officials determined that deploying Vice President Mike Pence, a former congressman with deep ties to many in the Senate, was a better bet than unleashing Mr. Trump on the half-dozen Republicans who will determine the fate of the Senate bill to repeal and replace the Affordable Care Act.” —Glenn Thrush and Jonathan Martin, New York Times

“Mr. Trump and his staff played a critical role in persuading House Republicans to pass health care legislation in May, with the president personally calling dozens of wavering House members. But the Trump team’s heavy-handed tactics have been ineffective in the Senate, and White House officials determined that deploying Vice President Mike Pence, a former congressman with deep ties to many in the Senate, was a better bet than unleashing Mr. Trump on the half-dozen Republicans who will determine the fate of the Senate bill to repeal and replace the Affordable Care Act.” —Glenn Thrush and Jonathan Martin, New York Times "Republicans May Have a Plan B If Their Health-Care Bill Fails" : “The close proximity of this fiscal year 2017 budget-reconciliation bill (which is technically what Senate health-care bill actually is) and its 2018 successor (which is what the tax-and-budget bill will be) raises a tantalizing fallback possibility for Republicans if McConnell can’t find a way to secure 50 votes for Trumpcare next month: A lot of what the first bill would accomplish could easily be rolled into the second.” —Ed Kilgore, New York magazine

“The close proximity of this fiscal year 2017 budget-reconciliation bill (which is technically what Senate health-care bill actually is) and its 2018 successor (which is what the tax-and-budget bill will be) raises a tantalizing fallback possibility for Republicans if McConnell can’t find a way to secure 50 votes for Trumpcare next month: A lot of what the first bill would accomplish could easily be rolled into the second.” —Ed Kilgore, New York magazine "Poll: Only 12% of Americans support the Senate health care plan": “Just 12% of Americans support the Senate Republican health care plan, a new USA TODAY/Suffolk University Poll finds, amid a roiling debate over whether the GOP will deliver on its signature promise to repeal and replace the Affordable Care Act.” —Susan Page and Emma Kinery, USA Today

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