What's next for health care in the Senate

— -- At a press conference Tuesday afternoon, Senate Republicans confirmed that they do not have enough votes to pass their latest bill to repeal and replace the Affordable Care Act (ACA).

While Senate Majority Leader Mitch McConnell announced they would not vote on the latest bill from Senators Lindsey Graham, R-S.C., and Bill Cassidy, R-La., this week, Republicans could return to their campaign promise to repeal former president Obama’s signature health care law down the road.

Graham told reporters Republicans may return to it again soon after they tackle tax reform.

In the meantime, some senators from both sides have expressed some interest in and optimism about bipartisan negotiations that had been taking place in the Senate Health, Education, Labor and Pensions (HELP) committee. Earlier this month, that committee held a number of hearings with governors, insurers and state officials about ways to lower costs and stabilize the individual insurance markets under the so-called Obamacare law.

Today, both the Republican chair and Democratic ranking member of the committee expressed willingness to come back to the table and attempt to reach a deal on smaller fixes to the current law now that a repeal effort had been shelved.

“We are ready to move forward on the kind of agreement they’ve talked about,” said McConnell, signaling leadership may be on board too.

Timeline challenges

After September 30, Republicans cannot pass legislation with a simple majority of 51 votes using the parliamentarian process of reconciliation -- however, they can try once again to vote using reconciliation in the next fiscal year. In order to do that, Republicans need to pass a new budget resolution with health care language in the House and the Senate.

"They could easily include language in the budget that preserved the option of including repeal and replace in reconciliation without committing to doing so or making it likely," said Ed Lorenzen, of the Committee for a Responsible Federal Budget.

But GOP leaders plan to use the process of reconciliation to pass tax reform. Leaving the door open to health care reform would likely complicate those efforts.

“If you had to put your money somewhere you’d put it on the side of ‘no big health care reform,’ and instead a focus on smaller things,” said Joseph Antos, senior health care policy expert at the conservative American Enterprise Institute.

“The possibility that some big Republican health reform will be back on the table seems awfully risky to me politically. There’s a midterm election next year,” he added.

Antos said issues for Republicans for reform will be “the very limited amount of time [to pass health care reform] combined with the difficulty of getting Republicans coalescing around anything, coupled with big donors in the health care industry who are really not eager to have everything shaken up again.”

The public is more concerned with Congress working to reauthorize funding for the State Children’s Health Insurance Program (CHIP), which provides coverage for uninsured children, and stabilizing current ACA marketplaces over trying to overhaul the nation’s healthcare system, according to September polling from the Kaiser Family Foundation, a nonpartisan research organization.

Still, GOP leadership and the White House remain committed to repeal and replace efforts.

“At some point there will be a repeal and replace, but we'll see whether or not that point is now, or will it be shortly thereafter. But we are disappointed in certain so-called Republicans," said Trump on Tuesday.

Returning to small, bipartisan solutions

Earlier this month, HELP set out to find ways to bring down premium costs under the current law. Their work was motivated, in part, because of another deadline -- Wednesday is the final date for insurance providers to sign contracts with the federal government so they can sell their coverage plans in the ACA markets in 2018. Many experts have warned that the unpredictability with health care laws and regulations could prompt those insurance companies to raise premium costs, especially for those who buy their own insurance.

As a result, stabilizing the individual markets has gained bipartisan support.

“Congress has an opportunity to slow down premium increases in 2018, begin to lower them in 2019, and do our best to make sure there are no counties where people have zero options to buy health insurance,” Alexander wrote Tuesday after leadership announced it would not vote on a repeal bill at this time. He said, as he has in the past, that he is concerned particularly for the 18 million Americans who buy insurance on the individual markets.

One of the biggest variables for insurance companies is whether the federal government will continue to subsidize premiums for lower income Americans who are buying plans off the individual insurance exchanges. The White House has often threatened to cut off those payments, which are a part of the ACA. Meanwhile, the HELP committee was exploring a deal to perhaps etch those payments into stone. But the payments are controversial -- conservative Republicans have argued the payments are just a taxpayer gift to insurance companies, and even Democrats agree that overall, the current law has not done enough to incentivize insurance companies to keep costs down.

In HELP committee hearings, Democrats also lamented recent cuts to Obamacare enrollment marketing efforts by Health and Human Services, while Republicans expressed their desire for more state flexibility with waivers.

While their priorities were different, the HELP committee did express a desire to find common ground, but the White House and House Speaker Paul Ryan said they were hesitant to back any bill that strengthened the current law instead of repealing it. If the bipartisan group of senators cut a deal, there is no guarantee the rest of Congress and Trump will get onboard.

"Democrats are at the table -- and I hope Republican leaders will now allow us to get back to work on lowering costs for patients and families and stabilizing the markets,” said Sen. Patty Murray, D-WA, at a Democratic press conference today.

Bargaining with pharmaceutical and insurance companies

During a CNN town hall debate on health care, Democrats and Republicans offered very different visions for the future of health care in America. Sen. Bernie Sanders (I-Vermont) continued to tout his Medicare-for-all plans, while Graham and Sen. Bill Cassidy (R-La.) defended their state-based solution to health care -- even as it remained on life support.

One area of common ground for the left and the right that emerged during the civil 90 minutes of debate on Monday was the need to reign in the costs of drugs.

“How do we work together? Here's one idea. One idea is to take on the pharmaceutical industry. You'll remember that Trump talked a whole lot during his campaign about thousand pharmaceutical industry was ripping us off. He was right. Let us work together,” said Sanders.

Cassidy agreed. “Controlling pharmaceutical cost is a bipartisan issue,” he said.

He added, “If someone can't afford their insulin, that's a problem…You should look at the profits for pharmaceutical companies. As those profits have climbed, so have your premiums and the taxpayer outlays. There's a relation between what you're paying and the profit they're getting.”