ROBERT COSTA: No holiday for health care. The Senate bill is stalled, the Affordable Care Act under siege. Many Americans just want to know, where does that leave me and my family? We have some answers, tonight on Washington Week. SENATE MAJORITY LEADER MITCH MCCONNELL (R-KY): (From video.) We know that we cannot afford to delay on this issue. We have to get this done for the American people. ROBERT COSTA: But delay they did. Senate Republicans punt the replacement health care bill past the July 4th recess as the divide continues between conservatives and moderates. Among the sticking points: Medicaid policies, tax relief for the wealthy, and assistance for low- and moderate-income Americans. SENATOR TED CRUZ (R-TX): (From video.) The central focus needs to be on lowering premiums. The current draft doesn’t do nearly enough to fix that problem. SENATOR SUSAN COLLINS (R-ME): (From video.) It’s difficult for me to see how any tinkering is going to satisfy my fundamental and deep concerns. ROBERT COSTA: Polls show most Americans do not support the GOP legislation, but leadership remains confident compromise is possible. SENATE MAJORITY LEADER MITCH MCCONNELL (R-KY): (From video.) Legislation of this complexity almost always takes longer than anybody else would hope, but we’re going to press on. ROBERT COSTA: Meanwhile, problems for the Affordable Care Act as more insurers are pulling out of the exchanges, and premiums, copays and deductibles are going up. Democrats insist the law should be repaired, not replaced. SENATOR PATTY MURRAY (D-WA): (From video.) Throw away this mantra of repeal Obamacare and work with us. ROBERT COSTA: We examine the state of health care in America with Sarah Kliff of Vox, Yamiche Alcindor of The New York Times, Michael Scherer of TIME Magazine, and Nancy Cordes of CBS News. ANNOUNCER: Celebrating 50 years, this is Washington Week. Once again, live from Washington, moderator Robert Costa. ROBERT COSTA: Good evening. Senate Republicans left Washington without passing a health care bill. Why? A revolt by conservative hardliners and moderates. President Trump says he supports the Senate measure, but this morning he delivered a mixed message via tweet. He wrote: “If Republican Senators are unable to pass what they are working on now, they should immediately REPEAL, and then REPLACE at a later date!” It prompted immediate questions about the bill’s political future, but for most Americans there are bigger questions than that. Tonight, we check the pulse of health care under President Obama’s Affordable Care Act and how it could change under the proposals that are being brought forth by Republicans. We will also share some viewer emails about the real-life struggles and concerns people have about coverage and care. Let’s start with the law better known as Obamacare. Today there are more than 28 million uninsured Americans. Who are these people? Well, they’re people who cannot find an affordable plan, people who decided not to get health insurance even they are qualified for a tax credit, low-income Americans in the 19 states that did not expand Medicaid, undocumented workers who are ineligible for coverage. And those who have coverage are facing other challenges. A viewer, Katherine in Florida, who works full-time, wrote us and said that insurance for her and her husband “runs a little over 18,000 a year… That’s twice what we pay for our mortgage.” Charles in New Mexico wrote: “My premiums and deductibles have escalated to the point that my insurance has been useless since the implementation of the ACA.” We got so many of these letters, and so many people concerned about coverage. But, Sarah, it’s not just coverage. For people who don’t have coverage and for people who do have coverage, they’re concerned about cost. How effective has the ACA been at lowering them? SARAH KLIFF: So it hasn’t really tackled what I think is the crucial problem in health care, which is the fact our prices are just so much incredibly higher. I hear from a lot of my readers who tell me these stories about going to the emergency room, and one of the stories I wrote about, they ended up with a $629 bill for just getting a Band-Aid on their child’s finger, and that is a uniquely American story. And I think one of the reasons the Affordable Care Act struggles, one of the reasons Republicans are struggling so much with their health care effort is that no one’s really talking about the prices, about actually lowering the per-unit cost when we walk into the doctor’s office, when we go to the hospital. One of the things that surprises me as a health care reporter is that Americans don’t actually go to the doctor more than people in other countries, it’s just every time we walk through that door we get a bill that’s double or triple other countries. The Affordable Care Act, it did include some reforms to reduce the overall volume of care, to kind of make doctors a little bit smarter about when they provide care, try and get them to order less unnecessary care. It didn’t take aim at the – at the actual prices, and I think that’s really at the heart of the frustrations Obamacare enrollees have, that the reason we have high deductibles, the reason we have high copays, it’s a product of those really high prices. MICHAEL SCHERER: And I think that was the political problem with Obamacare, because if you remember back in 2009, what President Obama was saying was we’re going to do two things: we’re going to expand coverage and we’re going to control prices. And so the American people thought prices would be under control, even though it never happened, and then from that point forward every time things went up again – you know, whether – even if you’re under employer coverage you’re paying more and getting less, your deductibles were going up. Republicans were able to say this is Obama’s fault when it wasn’t Obamacare that was raising the prices, it was the health system’s out of control and no one really has a way of putting a cap on it. ROBERT COSTA: And you know what’s been another fascinating part of this debate, is we’re really having a debate not just about the ACA, but about Medicaid. And Yamiche, you’ve traveled around the country, to Mississippi and Ohio recently, and you’re seen how this expansion of Medicaid that comes under the Affordable Care Act is having a real effect on people’s lives. YAMICHE ALCINDOR: Well, in my reporting the surprising thing that I found is that we talk about health care a lot of times, it’s OK, I’m sick, I go into the doctor, can I see a doctor, can I get treated, when Medicaid does so much other things. Medicaid pays for nursing homes. Medicaid helps special-needs students get their needs. Medicaid does these things for families, and covers them in a way that’s – that goes far beyond just showing up to the doctor and being sick. And it’s those people and it’s those issues, that’s why I think a lot of Republicans are worried about taking away Medicaid because they realize that Medicaid can really be a safety net for so many other things. I wrote a story even recently about a young man who was having strokes and was having seizures because he couldn’t have – he couldn’t get health insurance, and doctors partnered with housing to get him just an apartment, and it uses – Medicaid and Section 8 partnered that together to get him in a unit, and his seizures stopped almost immediately. And you think to yourself: if you’re homeless and stressed out and you can’t get access to Medicaid because someone hasn’t told you about it or because you’re poor and don’t understand it, the moment you can get just a little bit of help to get someone to help you understand what these programs can do for you, your whole life can change. So this is a guy who’s now in his 30s who can now go out and work and do other things. And that is what I think people are worried about when they talk about Medicaid. NANCY CORDES: And that’s part of the reason that so many Democrats and some Republicans are wondering why is Medicaid on the chopping block in this debate. Haven’t Republicans spent seven years saying that they’re going to repeal Obamacare? Why are they suddenly aiming to cut Medicaid by 35 percent over 20 years, according to the latest CBO analysis? And partly it’s because Obamacare expanded who can be covered under Medicaid, but also partly it’s because in the House, where this all originated, it’s something that has been a dream of Paul Ryan’s for decades, is to scale back Medicaid, he says to make it more sustainable. And it’s also because Republicans are trying to generate some revenue in this bill so that they can then go ahead and move on to tax reform. ROBERT COSTA: That’s such a smart point because this bill – the Affordable Care Act is no longer just a political football, it’s something that’s actually associated with people’s health coverage and their benefits. And, Sarah, it’s not just people associating the ACA with Medicaid, but Republicans are railing against the taxes under the ACA, the regulations under the ACA, trying to get rid of a lot of those things. But there’s also preexisting condition coverage within the ACA that’s made the bill quite popular, made the law quite popular. SARAH KLIFF: Yeah, that’s definitely a big part of the Affordable Care Act, and I think it really speaks to how entrenched the health care law has become in our society. I think this is something Democrats really hoped for. They kind of expected once this rolls out, once people get coverage, they won’t want people to take it away. I remember an advocate once told me, you know, we’ll know this law has made it when people say “take your government hands off my Obamacare” – (laughter) – like people say that about Medicare. And those reforms have become entrenched. People like the preexisting conditions ban. They really like that. But Obamacare, because it is associated with a president who, you know, really was quite divisive in this country, it has not as a concept become something that Democrats up until very recently, and definitely not Republicans have rallied around and, like, said I want to protect this law. ROBERT COSTA: So people may like the Medicaid provisions. They may like some of the protections. But, Michael and Yamiche, when you travel and you report you know that you hear a lot of complaints about the insurance markets not working. MICHAEL SCHERER: Right. So when people say they’re upset about Obamacare, they’re usually saying they’re upset about what they’re paying for health care, and that’s not what this bill that’s been proposed is going to address. This bill is a very large tax cut. It’s a long-time entitlement cut that Republicans have been looking for for 30 years, it has nothing to do with Obamacare, the cuts to Medicaid, like Nancy said. And it’s an effort to change the structure of insurance so people can pay lower premiums and get less care. But the things that people are worried about are still going to be here in five years or 10 years. And now Obamacare won’t be the boogeyman. It’ll be something else. YAMICHE ALCINDOR: I think when I’ve talked to people the thing that’s interesting is the thing that they love is, like you said, preexisting conditions and being able to have that. And I think that that’s across the board, Democrats and Republicans, when I’ve interviewed voters in the campaign and then afterwards in this – since President Trump took office. The thing is that people also have heard, even though – and sometimes it’s rare – that people also don’t like the fact that the government told them that they had to buy a product. So there are these people that love the fact that they have – that they can get covered with preexisting conditions, but don’t really understand that it’s because healthy people had to buy insurance. That’s why you can pay and convince companies to say, OK, well, you’re going to have really, really sick people, but you’re also going to have these young, fresh people that are going to be able to pay into the system, and you likely won’t have to pay for. So those are the two things that I’ve found that people are very angry about. I think it’s also, in all this conversation, Obamacare, the fact that it’s named that, it, to me, as a reporter, I found it to be two things. People are very angry at just the politics of it. And frankly, people are also – I think there’s always going to be a racial dynamic to this, which is that people don’t like the fact that they had to think about this president. So people who, one, didn’t like the president or political reasons, but also people who just don’t like the president or they don’t like – they didn’t like what he represented as a country – how he represented us as a country, they also have that problem going on too. NANCY CORDES: And I think the fact that Obamacare is now becoming more popular after he left really proves that point. YAMICHE ALCINDOR: Yeah. Good point. (Laughs.) ROBERT COSTA: On that point, Nancy, do you – we always hear about the Republican effort to repeal and replace, but are Democrats post-Obamacare being passed – are they actually looking for more government involvement? Could a single payer system, more federal spending, could that be on the agenda if the Democrats ever get back power? NANCY CORDES: Oh, in their dreams. (Laughter.) There are certainly a lot of Democrats who would love that, and still think that that is the way to go, that that’s the best way to bring down prices, as Sarah was talking about. But they’re pretty realistic and they know that that’s not going to happen anytime soon. That doesn’t stop them from talking about it right now as kind of a negotiating ploy. They’re sitting there going, well, if Republicans are going to talk about slashing Medicaid and repealing everything about Obamacare, then we’re going to say that we’re for single payer, and maybe we’ll meet somewhere in the middle. Right now, they’re basically just sitting on the sidelines and watching and hoping that Republicans cannot craft a compromise within their own party, because then that suddenly gives Democrats some power, which is something that is pretty short supply for them these days. ROBERT COSTA: It’s amazing to watch Republicans and Democrats have this different response. If the law collapses for some reason or has real problems, Democrats think there could be more government as an answer and Republicans think less government would maybe be the answer. Let’s talk about the Republicans’ plan, because this is dominating Capitol Hill and it’s currently stalled in the Senate. It’s been stalled there for days. The CBO estimates 22 million people would be left uninsured over the next 10 years under the GOP plan. New polls show it’s pretty unpopular, that most Americans don’t support it, only 17 percent of those surveyed in the NPR/PBS NewsHour/Marist poll. Twelve percent in the USA Today/Suffolk University poll – 12 percent. And the Fox News poll found only 27 percent of Americans approve of the Republicans’ plan. While Majority Leader Mitch McConnell continues to rally votes, fellow Kentucky Republican Rand Paul, a doctor, remains one of the most strident health care holdouts. He wants the Senate to do something interesting, to go ahead and fully repeal Obamacare, then work on a replacement later. Some Republican governors are also working against the measure, and it’s put McConnell in a box. We see this, Sarah, with the Republican governors. These are not Democrats. Republican governors, it comes back to this point we’ve been discussing about Medicaid being popular in terms of how it’s expanded in these states. They seem to be a key stakeholder in this debate. SARAH KLIFF: They really are. And they’ve been much more vocal than I would have expected. But they have good reason to be. A lot of these Republican governors are getting a lot of money in their states for Medicaid expansion. And this is especially important when states that are suffering from opioid epidemic, places like Ohio where John Kasich is governor, that they really feel like they need that kind of safety net, they need Medicaid expansion to continue. One of the things that was really surprising was last week we saw Nevada’s Governor Sandoval give this press conference where he honestly sounded like a spokesperson for Obamacare. He’s a Republican governor talking about how important this law has been, how great it has been. And it is interesting to see this intraparty divide where they can’t rely on these governors as validators. ROBERT COSTA: And Sandoval’s the one who pressured Senator Dean Heller, a moderate Republican, to not back the bill. SARAH KLIFF: Yeah. ROBERT COSTA: And, Michael, you’ve written extensively about the power of the GOP governors. Could they tilt this whole debate? MICHAEL SCHERER: Yeah, I think they already are in Nevada. You see Rob Portman being hesitant in Ohio. And that’s because John Kasich’s the governor. There’s concerns in New Hampshire as well with Sununu, although they have Democrats there. But I think that’s having an impact. It’s not just the Medicaid expansion. One of the things that hasn’t been fully debated, because I think it hasn’t been presented to the American people, is that under this Senate plan and under and in a slightly differently way under the House plan, after 2025 it’s not just the Medicaid expansion that goes away, it’s that Medicaid as it has existed since 1965 changes. The way the program has existed is if you have someone who meets these criteria, you pay for them and the federal government will match a significant amount of that money – no matter how many people you have. You have more people, you get more money, you have more sick people, you get more money. Under this plan, after 2025, the money is capped. They cap it in slightly different ways. And then it’s indexed to regular inflation. And that’s really important because that means over time health care costs are going to keep rising faster than regular inflation. Over time, the Medicaid program shrinks more and more. So these governors when they’re looking at this are not just thinking about the people who’ve gained insurance. They’re thinking about, OK, in 10 years or five years I’m going to be faced with trying to tell people they can’t be in nursing homes, or trying to tell sick kids who have very expensive treatments – ROBERT COSTA: So, does this kill the bill, Nancy? NANCY CORDES: Well, I interviewed Governor Kasich this week. And I said, you know, Senate Republican leaders say they’re giving you all this new flexibility as a governor that you didn’t have before. And he said: Well, what’s the point of flexibility if I don’t have any money? Then I really don’t have any more flexibility than I did before. I probably have less. And I think it’s – it just is emblematic of the fact that Republican leaders, as they’re trying to sell this plan to their own members, to the public, don’t have many outside allies to turn to. You would imagine that Republican governors would be their champions. Instead, they’re either sitting on their hands or arguing against it. YAMICHE ALCINDOR: But when we talk about essentially block granting Medicaid, which is what a lot of the experts call it, capping it in that way, the experts I’ve been talking to, to go right back to the 1990s and say, remember block granting the welfare reform when we all thought it was great to block grant TANF and cash assistance? Cash assistance almost doesn’t exist anymore in many states because of this block granting. The fact that you give a very limited number of money to a state and say, you can decide what to do this, it changes exactly the criteria. You end up having to have new eligibility requirements so that states somehow figure out who are the most neediest of the neediest of the neediest. And that’s why you end up with people needing cash assistance. And in some ways, it’s going to end up like housing, where there are so many people who need housing assistance, but only a fraction of the people that can actually get it. ROBERT COSTA: So these issues all cloud the debate as McConnell looks for votes over this July 4th holiday. Is there a way, Sarah, for the majority leader to get moderates on board by giving them tweaks to the Medicaid provision of this bill, and also getting conservatives on board by giving states more flexibility with the regulations? Do you see that actually as a political possibility? SARAH KLIFF: Well, they were able to pull it off in the House. So I would say it is not something that is impossible. I think one of the things that’s instructive when I think about how this happened in the House, is we also saw there a failed vote, Paul Ryan couldn’t get the votes together, people took a few weeks off, they came together, and they came to an agreement. I don’t think we can underestimate the drive of Republicans to repeal this law. And the – ROBERT COSTA: Because this is a promise they’ve made for years? SARAH KLIFF: Exactly, yeah. And the – nobody wants to be the person standing in the way. As different people kind of say, yes, we can get behind this, yes, we can support this, it’s hard to be in the hot seat and say, you know, you’re the person standing in the way. ROBERT COSTA: Michael, what are we supposed to make of President Trump in all this? He’s called the House bill mean. He said any bill that passes should have heart – that’s his phrase. And we also see him kind of getting behind this Republican idea of full repeal, just get rid of the law, and then maybe come back to it in a few months. What to make of it? MICHAEL SCHERER: Well, I think “heart” and “mean” are about as specific as he’s been about this policy. He doesn’t really get into the weeds here. What he said this morning in a tweet, which was then sort of contradicted by Sarah Huckabee Sanders in the briefing, was maybe we just do repeal. That seems to me like a negotiating tactic, not a serious – NANCY CORDES: And it was greeted with a big eh on Capitol Hill by Republicans. (Laughter.) They said, well, he’ll probably have a different solution 24 hours from now, so I’m just not even going to pay attention to it. MICHAEL SCHERER: But I think the answer to your question is that President Trump wants a win. And President Trump wants to move onto tax reform. And it’s pretty clear that if this crashes and burns over the next few months, it’s going to be harder to get tax reform, not just because you won’t have the money to play with to lower rates later on, but because the dysfunction will only continue to grow. YAMICHE ALCINDOR: But they also understand – Republicans understand that even if they give him a win, if at some point people realize exactly how terrible this bill is, that they’re going to be completely on their own – the fact that he will not – he will not – he will absolutely go out there and say, well, this was Congress’ fault and I tried to get you the best bill, and this is what they gave me so I signed what I had. Like, I think when we talk about Twitter, we obviously sometimes say that, you know, this is just a shrug and this is Trump being Trump, but in reality it’s turned into a political atmosphere where people do not trust him, which means that he is going to be a calculation that people are going to realize is a wild card. NANCY CORDES: He has limited influence on these senators because they now believe that he’ll tell them one week to vote for this bill, they have to do it for the sake of the party, and then the next week he’ll say it was a terrible bill and leave them hanging. And then, beyond that, he’s been the perfect example that you don’t always have to toe the party line, that you can go out there on your own, you don’t have to always sacrifice for the party to get ahead. And so they’re looking at his example. He’s in the White House. ROBERT COSTA: And they see him really as the base, the living embodiment of the Republican base, who wants this box to be checked. But they’re weighing the political cost, as well, ahead of the 2018 midterms. What happens if millions do lose insurance? NANCY CORDES: Right. And if you’re – if you’re Dean Heller from Nevada, you are more worried about what your own constituents face under this new bill than you are worried about, you know, the fact that Mitch McConnell’s going to be angry with you if you don’t side with him. MICHAEL SCHERER: And even if you’re talking about the base, you have to define your terms because there is the traditional ideological base, which wants less government, they wanted Obamacare out. Then there’s also the Trump populist base, who believed Trump during the campaign when he said I’m not going to cut Medicaid, I’m not going to cut Medicare, I’m not going to cut Social Security, I’m going to give the working poor, the lower middle class more, not less. And here he is pushing a bill that will give them less, not more, and he’s paying – he’s taking that money and very directly, at least right now, giving it to wealthy people. ROBERT COSTA: Why do you think, Sarah, that the president got behind the ideology of House Speaker Paul Ryan and conservative Republicans if, as Michael said, he’s not really inclined to do this kind of sweeping overhaul? SARAH KLIFF: I think it goes back to what we were saying earlier, that he’s someone who really wants a win. I also think he’s not very engaged in the policy details. So there was a really revealing interview, I thought, he did with I believe it was CBS’s John Dickerson, who asked him some very basic questions about the bill, like what does this do, who does this cover, and he would say things like everybody is covered, deductibles are going to go down. And those just simply aren’t true about the bills that Republicans are proposing, that these are bills that will cover fewer people, raise deductibles. You know, I think it’s a good point about the people who voted for Trump. I’ve spent a lot of time in an area of southeastern Kentucky that went overwhelmingly for Trump, there’s really high Obamacare enrollment, and these people, they listened to the campaign. They watched those debates. They saw Trump promise I’m going to fix this health care system. And I think what they heard is that, you know, I am frustrated with the prices, I’m frustrated with the costs, and this president is a guy who’s going to make my health care costs less. And he is not working with a bill right now that would deliver that promise. ROBERT COSTA: And Yamiche, a lot of people in Kentucky rely on the ACA, people you’ve met and covered. YAMICHE ALCINDOR: Yeah, so I was actually in Jackson, Mississippi recently, and the thing that I take away from Trump – both Trump supporters, but also other people is that they – while they voted for Donald Trump and understand that, they also are sticking with him in this way that to me is still very interesting to me. So the budget comes out and the administration says, you know, Social Security disability isn’t really Social Security, even though it’s named Social Security disability. And I went to Mississippi and I talked to people and said, you know, you’re going to lose your coverage, and they were like, well, I understand that the president has to make difficult decisions, and I’ll figure out how it is as long as he builds that wall. So the idea is that people are also willing to, in some ways – at least I’ve found in my reporting – are willing to in some ways suffer for the idea that Donald Trump is going to do all these other things. He’s going to keep the other people out of the country. And that is something that’s really important. NANCY CORDES: I was talking to Susan Collins the other day and – ROBERT COSTA: Senator from Maine. NANCY CORDES: Senator from Maine. ROBERT COSTA: Moderate Republican. NANCY CORDES: And, you know, she handed me this chart. And I don’t expect you to be able to see this, but she’s handing it out to everyone who she talks to. And basically it’s – ROBERT COSTA: What does it say? NANCY CORDES: It’s the potential cost under this new bill for someone in Aroostook County, Maine – northern Maine; I probably mispronounced it, you’ll probably get viewer mail from all your Maine viewers – but you know, according to her calculations, this is – these are the deductibles under the new plan. Her average resident is going to pay 5,500 (dollars) in deductibles, compared to 800 (dollars) now. So the key promise of Republicans leading up to this bill has been we want to bring premiums down, bring costs down, and this does not do that. ROBERT COSTA: And I bet every Republican senator who’s evaluating this bill is looking at a chart just like that. NANCY CORDES: Exactly. ROBERT COSTA: What’s the cost for my state? Not for the party, perhaps, but for my state. NANCY CORDES: And she’s saying until this looks better, I’m not voting for it. ROBERT COSTA: She’s going to – she’ll probably be on the fence. We have to end it there, my friends. Thanks, everybody. Our conversation will continue online on the Washington Week Extra, where we’ll talk about the backlash over President Trump’s fake TIME Magazine cover and his tweets about a couple of morning news anchors. You can find that Friday night after 10:00 p.m. at PBS.org/WashingtonWeek. And don’t forget to tune in next Tuesday night to PBS’s A Capitol Fourth, the annual all-star music and fireworks celebration. For now, I’m Robert Costa. Thanks for watching, and enjoy your weekend.