The Senate Cant Pass Health Care Without This Man

Bill Cassidy, the first-term Republican senator from Louisiana, thinks the House’s Obamacare repeal bill failed to consider the impact it will have on one crucial constituency: patients. A medical doctor whose political life was forged in the aftermath of Hurricane Katrina and during decades working in a charity hospital, Cassidy wants a more robust replacement for Obamacare, one that lives up to Donald Trump’s campaign promise to replace it with a law that covers more people at a lower cost.

That might sound like wishful thinking, yet if Senate Republicans want to do anything on health care, they have no choice but to listen to Cassidy. Although he wasn’t included in the 13-member working group tasked with crafting a Senate bill, Cassidy has emerged as perhaps the most critical vote—the elusive Republican who can make or break Trump’s top legislative priority.

With 52 seats in the Senate, the GOP can afford to lose just two of its own and still pass a bill without Democratic support. Given conservative insistence on defunding Planned Parenthood as part of the effort, Republicans could, for instance, lose the support of moderates Susan Collins of Maine and Lisa Murkowski of Alaska. That would set up a scenario where Cassidy becomes the decisive vote and Vice President Mike Pence casts a tiebreaking 51st vote, with Democrats powerless to filibuster under special budget reconciliation rules.

Cassidy wants a bill that lowers premiums and expands coverage, and says the American Health Care Act passed by the House fails to deliver. The Congressional Budget Office estimates the House bill would lead to much higher premiums for poorer seniors; 23 million fewer people would have insurance by 2026. “If they come up with a solution that makes that person who’s struggling with premiums now struggle even more, I’m on her side,” Cassidy says. “And I will fight for her. And that’s where my loyalty lies.”

Cassidy has been in politics for a little more than a decade—first running for state office after Katrina exposed a government unable to protect its people. In the days after the 2005 hurricane, he organized a makeshift medical center in an abandoned Kmart. “I’ve known Bill since before he got into politics,” says fellow Louisiana Republican Senator John Kennedy. “He’s whip-smart, and as big as his brain is, he’s got an even bigger heart.” After stints in the state legislature and the U.S. House of Representatives, he beat Democrat Mary Landrieu in 2014, in part with a message that helped sweep Republicans into power nationwide: Repeal Obamacare.

Cassidy has sometimes bucked his own party, including in 2014 when he worked with Democrats to reinstate lower flood insurance rates, a move that temporarily cost him his seat on the House GOP whip team. He’s also forged a close relationship with Maine’s Collins. The pair sit next to each other on the Senate’s health panel, and Cassidy recruited Collins to collaborate on a health-care bill in the last Congress, knowing she’d overseen Maine’s bureau of insurance for five years. “He has experience working in a public hospital, and that gives him a great deal of credibility,” Collins says. “He makes what is a point that everyone needs to be reminded of, and that is that someone eventually is going to pay for the care” of the uninsured.

The Cassidy-Collins bill, introduced in January, would keep most of Obamacare’s taxes in place to pay for a more robust replacement. “It is the fiscally conservative position to actually pay for that which you are promising,” Cassidy says. His biggest idea is to replace the individual mandate with a rule that allows states to auto-enroll people in insurance—a potential key to getting younger, healthier people into the market and lowering overall costs. Cassidy borrowed the idea from the 401(k) industry, which for years has pushed states and companies to make people opt out, rather than opt in. “If it is an opt-out, you get 95 percent of the folks participating,” he says. “If it is an opt-in, you start at 60 percent and you work up with a lot of education. So taking 401(k) data, kind of behavioral economics, you allow states to do automatic enrollment, and you immediately expand the risk pool.” Cassidy says an insurer modeled a plan with automatic enrollment that shrunk premiums 20 percent.

To spur competition, he also wants new price transparency requirements tied to federally funded health savings accounts for poorer people, who will have an incentive to find cheaper providers. He thinks insurers should be allowed to charge older people as much as seven times what they charge younger people for premiums. To even that out, Cassidy would give them seven times the tax credit. Those changes, he says, would make premiums affordable enough that younger people would stay in the pool while providing older people enough money to keep plans economical.

In a rare bid to attract Democrats, Cassidy would also like to give states the option to keep most of Obamacare if they like it. “There is no long-term social solution that occurs in our society unless it’s bipartisan. And I love history, and that’s what history teaches me,” he says. But so far he’s gotten little more than a nibble from Democrats, which he blames on politics. Democratic senators know the current system is dysfunctional, and Cassidy is frustrated they won’t engage in serious talks unless Republicans drop their plans to use a procedure aimed at preventing filibusters. Two years into the Senate, he’s still surprised by how little consideration his colleagues give to the plight of their voters. “I’m thinking, Why were you elected? It’s just the most amazing thing in the world. You were elected to take care of your folks, even if they’re not quite the rules you would prefer.”

Cassidy, meanwhile, has gone from being a little-noticed, quiet backbencher to a staple on cable news. In a rarity for any senator, he made his late-night TV debut on May 8 when he appeared on Earlier that month, after Kimmel made an emotional appeal against the House bill, sparked by his newborn son’s congenital heart problem, that went viral, Cassidy declared on Twitter that any bill should pass the “Jimmy Kimmel test.” In other words, insurance companies shouldn’t be able to cap payouts to customers, preventing, for example, a sick newborn from getting the care he needs. On the show, Kimmel immediately got political, asking Cassidy why Republicans are against making sure Americans have adequate coverage. Cassidy replied by invoking Trump’s campaign promise of lowering premiums. “We have got to have insurance that passes the Jimmy Kimmel test, but a middle-class family can no longer afford it,” said Cassidy. When Kimmel suggested that Republicans keep Obamacare’s taxes on the wealthy to pay for health care, Cassidy urged viewers to call their senators. Surely, some of his GOP colleagues were watching.

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