Sarah Kliff of Vox talks with NPR’s Audie Cornish about ways the executive branch can undermine the Affordable Care Act, after the Senate failed to pass legislation repealing the health care law.

AUDIE CORNISH, HOST:

Over the weekend, President Trump tweeted, if a new health care bill is not approved quickly, bailouts for insurance companies and bailouts for members of Congress will end very soon. That’s a threat to end subsidies that benefit low-income Americans who are insured through the Affordable Care Act. It’s also a threat to end subsidies specific to health plans for members of Congress. Now this tweet, among others, adds more uncertainty about the future of the Affordable Care Act after Friday’s failure to repeal and replace it.

Joining me now is Sarah Kliff. She’s a senior health care policy correspondent for Vox. Welcome to the program.

SARAH KLIFF: Thank you for having me.

CORNISH: Let’s start out with that term bailouts, the payments that the president is threatening to withhold. Tell us more about what he’s talking about and whether he could actually do what he’s threatening.

KLIFF: Yeah, so he’s talking about two things. And I’ll tackle the one for insurance companies first, and then we can go from there. So he is talking about these funds that we call cost-sharing reduction payments. This is about $8 billion that the federal government sends to insurance companies to offset the copays and deductibles that low-income patients on the Obamacare marketplaces have.

What the Trump administration is threatening to do and what they could do is say they are going to stop paying those cost-sharing reduction subsidies. That would cause a lot of chaos in the marketplaces. Experts estimate that premiums would rise 15 to 20 percent if that fund went away.

CORNISH: Now, President Trump regularly talks about letting the Affordable Care Act, quote, unquote, “implode.” In the meantime, what are the actions the Trump administration has already taken that could effectively undermine the law? What’s happened since he’s taken office?

KLIFF: A lot of it is just the uncertainty about how he is going to manage the Affordable Care Act. And for insurance companies, they don’t like uncertainty. Insurance companies love to know exactly what they’re pricing for, who’s going to sign up, how much their medical bills are going to be. So you know, it isn’t necessarily the case that they’ve put out specific policies to damage the Affordable Care Act. It’s mostly they don’t make clear what their policy positions are. And that’s actually quite damaging in itself.

CORNISH: But Democrats look at things they’re doing like saying withholding the advertising – right? – so people don’t know kind of when and where to sign up and say, look; that’s an example of sabotage.

KLIFF: Yeah, that’s a good point. You certainly do see some ads being pulled off the air in January. Just last week, the Trump administration cut off a grant to 18 cities to do enrollment work. So you’re seeing some small amounts of that. But we’ll really get a big test when we get into open enrollment in November and see, you know, is the Trump administration letting people know about open enrollment? Is it easy to get through to the call center? Are there lots of people staffing it? Or are there long waits? These are all kind of small, practical details, but they really add up in terms of whether people get health insurance or not.

CORNISH: So far, has there been an actual effect, right? Like, what has been the result of the actions they have taken?

KLIFF: So we did see enrollment go down a little bit at the end of the open enrollment season this year. This was just a few weeks after the Trump administration came into office. It’s hard to know how much of that was related to specific actions they took, but it is certainly true that we saw enrollment dip a little bit. And this is after some of the advertising was pulled. The other place we’re seeing it right now are where insurance companies say, our premiums are higher because of the way the Trump administration is managing the Affordable Care Act.

CORNISH: Let’s say we hear Republicans and Democrats are working together in a bipartisan way to improve the Affordable Care Act. In another part of the program, we’re actually talking to some House lawmakers trying to do that. Are there some obvious fixes?

KLIFF: Yeah, there certainly are, and they’re being talked about on Capitol Hill right now. One of the biggest is requiring the payment of those cost-sharing reduction subsidies, writing it into law that this money exists, that it goes to insurance companies.

The other thing that comes up that, you know, insurance companies really want is some kind of fund to offset their really expensive patient so that when they get someone with a million dollars in medical bills, that they have some kind of backup fund from the federal government. This is typically called reinsurance. And insurance companies say they would feel more comfortable enrolling Obamacare enrollees if they had that assurance they wouldn’t go broke if they get one really expensive patient.

CORNISH: For people listening who do have insurance coverage through an Affordable Care Act or Obamacare exchange, should they expect any changes to their health care or insurance just in the coming months?

KLIFF: A lot of that depends on where you live. I’d say generally the picture nationally is – we are seeing possibly some significant premium increases in 2018 because insurance companies are not sure about those cost-sharing reduction subsidies. The Blue Cross plan in North Carolina, for example, is tacking 14 percent onto their premium rate increase.

But states, particularly those that have done a lot of work to mitigate some of this uncertainty, a place like California, you’re not going to see a lot of change. But then you have other places that haven’t been as enthusiastic adopters. And I should also mention we right now have 19 counties across the country in Indiana and Nevada with no insurance plans signed up to sell coverage in 2018. If that doesn’t get fixed, those people will not be able to purchase an Obamacare plan next year.

CORNISH: Sarah Kliff is senior health care policy correspondent at Vox. Thank you for speaking with us.

KLIFF: Yeah, thank you.

(SOUNDBITE OF PILOTE SONG, “SHAPESHIFTER BLUES”)

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NPR transcripts are created on a rush deadline by Verb8tm, Inc., an NPR contractor, and produced using a proprietary transcription process developed with NPR. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.

Columnist and former speechwriter Mary Kate Cary, political strategist Ron Christie and public affairs strategist Brian Wise discuss the week’s White House shake-up, as well as the health care debate.

NOEL KING, HOST:

It’s time for the Barbershop, where we talk with a group of interesting people about what’s in the news and what’s on their minds. It’s been another big week in Washington – no exaggeration. For now, the GOP health care bill is dead. The new White House communications director, Anthony Scaramucci, has made himself known. And questions about the president’s relationship with Russia continue to swirl.

We wanted to get a conservative take on all of this. Joining us now for a shape-up, our columnist Mary Kate Cary. She’s a senior fellow at the Miller Center at the University of Virginia. She’s also a former speechwriter for the first President Bush. She’s with us in D.C.

Welcome, Mary Kate.

MARY KATE CARY: Thanks for having me.

KING: Also with us in D.C. is Brian Wise. He’s a political commentator and public affairs strategist. Hi, Brian.

BRIAN WISE: Hi. Good to be here.

KING: And joining us from our studios in New York is Republican political strategist Ron Christie. Ron is a former special assistant to the second President Bush. Ron, thanks for coming on.

RON CHRISTIE: Noel, nice to be with you.

KING: Ron, it has been a big week at the White House. Let’s start out with the most recent explosive news. Reince Priebus is out. Why did he have to go?

CHRISTIE: Well, I think the most important job that the White House chief of staff is, is beyond being the gatekeeper, beyond being the one person who can stand up to the president and say, Mr. President, no, Reince Priebus did not exhibit strong leadership. No one in the Cabinet feared him. No one in the White House feared him. The president didn’t respect him.

And the job – the severity of the task that you have as the White House chief of staff, if you don’t have the trust of the president and you don’t have the loyalty of the staff, let alone the fear of the staff of being displaced for any reason at all, you have to go. And I think the president did the right thing. He needed to bring in someone who could impose discipline, to impose order in the White House and, most importantly, to right the ship that team Trump right now is just not doing very well to advance our legislative priorities.

KING: Mary Kate Cary, before the word came out about Priebus leaving, he was in the news for some comments made by his colleague, the new communications director, Anthony Scaramucci. Mr. Scaramucci gave a very colorful interview to The New Yorker. He took shots at Priebus. He took shots at Chief Strategist Steve Bannon. I mean, you’re a communications professional. What did you think when you saw all this?

CARY: I frankly was just appalled. It was, from a communications point of view, just jaw-dropping, to me. And, you know, I did hear one funny line in Washington which was his new nickname is going to be the Moochnado (ph), as in “Sharknado”…

KING: Oh, dear.

CARY: …Which I think is, of course, the greatest film of all time. But the Moochnado really took everything – took all the oxygen out of the room in Washington and took the president off his agenda for the umpteenth time. And I think that was – that’s the bigger problem here is all of this sideshow keeps taking away from the president’s agenda.

KING: I mean, Mary Kate, we hear that the president likes his employees infighting, that he thinks feuding is good for them, it keeps them competitive. Do you think he recognizes, though, that if they are fighting, his agenda isn’t moving forward? That’s how it seems, anyhow.

CARY: Yeah, that’s how it strikes me. There’s – in every White House, there is backstabbing and infighting and all that. It just rarely spills over into the public like this and overtakes everything else. So that’s what was so shocking about it, this week, was the level of public display.

KING: Brian Wise, you are a strategist. We’ve got a new incoming chief of staff, General John Kelly. And we assume he’s a tough guy. He’s a general. If you could give him some advice, at this point, what would you say?

WISE: Well, first of all, I wouldn’t presume to give advice to one of the most highly respected military leaders of our time. But I do think it’s important to understand that, in the White House, you have management officials and you have advisers. And General Kelly is going to be an exceptional manager of the White House. And that’s one of the things that I think the White House has been missing for the last six months. However, someone like Anthony Scaramucci may be a great adviser to the president.

You know, every corporate executive needs a conciliary, if you want to talk about it in the way that maybe Scaramucci might understand. And Scaramucci is going to be the president’s conciliary here. He is going to be the adviser that is loyal to the president, not necessarily loyal to the White House administration or even the country in general.

KING: But the idea is that General Kelly, being a general, may be able to keep things in line.

WISE: He’ll bring the discipline, and Scaramucci will bring the color.

KING: All right, they could be a good team. The big legislative news this week was the collapse of the Senate health care bill, the so-called skinny repeal. Three Republicans bucked party lines to vote against the bill. It ended up going down by one vote. Ron Christie in New York, you and I have known each other for a while. And I know that you are very big on integrity. Senator John McCain’s no vote got a lot of attention. And people said, the maverick is back. What did you think?

CHRISTIE: Well, the maverick is definitely back. And yes, we’ve known each other for several years. And I’ve been pretty consistent on saying that integrity and loyalty, those are your two calling cards in politics. And Senator McCain made a grand display of coming back to Washington to cast a vote to have the motion to proceed to move forward on health care. And then he stabbed his party in the back. He voted no.

Why would you do that when we have the largest governing majority since 1929 in the House and the Senate and the presidency and undermine your party’s efforts for the last seven years of saying that we’re going to overhaul the Obamacare or the Affordable Care Act legislation? What did I make of that? For one who claims that he’s a man of honor and dignity, I thought this was the ultimate betrayal that Senator McCain did to his party and to his country for so many millions of people who are hurting by this health care law.

KING: Mary Kate, what do you think about that?

CARY: I felt earlier this week, when I saw that speech, that that was a speech for the ages. Just as a person in that world, I thought it was tremendously well-written and well-delivered and…

KING: And this is the speech in which McCain…

CARY: Spoke on the Senate floor and apologized for his role in the increasing lack of bipartisanship in Washington and called for a return to regular order. But he did say in that speech, I will not support this bill as it stands. So I was not totally surprised that he did not support the bill because he warned that he would do that if it didn’t change. And it, as far as I could tell, it didn’t change between then and the vote.

KING: Brian, at this point, the GOP is so internally divided with so many factions pulling in so many different directions. What is it going to take for Republicans to get past this internal gridlock?

WISE: I think the important thing to understand is that this is not a single party. This is a party of three different distinct factions. You have the social conservatives, the fiscal conservatives and the defense hawks. And in order to bring those people together, you need a kingmaker. The GOP has not had a kingmaker, really, in 10 years since Karl Rove left the White House. And without a kingmaker, you can’t unify the party or exert influence over members that may be inclined to vote against the party line.

And so what we need is that leader empowered to come in and bring the party together. I think the only person for that, at this point, is Mike Pence. The vice president has the power, has the support of all of those different factions. And if he was empowered by, not only the president, but also party donors, party leaders and other stakeholders of the party, I think the vice president could really be the savior of the Republican Party here in 2017 and moving forward.

KING: Do people – Mary Kate, you’re shaking your head…

CARY: Yeah…

KING: …You agree?

CARY: …I would agree…

KING: Yeah.

CARY: …With that. His former staff from the Hill is throughout the White House in legislative affairs, in communications, and I think that could be the way forward for a lot of people.

KING: We’re six months into this legislative term. We haven’t even talked today about the ongoing Russia investigation, the open tension between President Trump and his attorney general. With all that said, Republicans have control of the White House and of the Congress. What is it going to take for them to pass legislation? Ron Christie, let me start with you.

CHRISTIE: Well, they need to grow up. I mean, they actually need to figure out how to govern. And as I said a few moments ago, I mean, we’ve had the largest governing majority since 1929, and they can’t even move forward on a motion to proceed. Republicans need to say, you know what? Here’s who we are. This is what we stand for. And if we can’t govern, we need to get out of the way. It almost looks like they’re the party of being the complainers rather than the party of being governors.

KING: Mary Kate, what’s it going to take?

CARY: Well, you know, I’m a speechwriter, so I come from that angle here. Unlike tweets, speeches bring a tremendous amount of consistency, fact-checking, policy guidance, a lot of buy-in from a lot of people. And I think one of the reasons the health care bill went down was because the president did not travel the country making the case publicly in speeches to rally the American people behind it. So that would be my advice would be to get him out on the trail and giving policy addresses where he’s not ad-libbing as much as he was this week and see if he could take back the agenda.

KING: Keep some of those speeches on message…

CARY: Right.

KING: …It sounds like you’re saying. Brian Wise, there’s been a lot of talk that this has been a very bad week for the president and for the party. Ultimately, though, does that matter?

WISE: You know, at the end of the day, this is no surprise to the American people. This is the president that they voted for. This is the deal that they made with him. This is a transactional president. This is not an ideological president. And after having experienced an ideological president for the last eight years, I think it’s a little bit of a shock to people that there could be someone who was so transactional as President Trump.

So it shouldn’t be a shock to anyone that he is managing the White House in this way, he is managing public policy issues in this way because that’s the deal that he made with the American people. Moving forward, I think that that leadership – I think General Kelly coming in and the changes that are currently happening at the White House will be good for, not only the White House, but good for America.

KING: All right, there you go. We’re just about out of time. Thanks so much to Mary Kate Cary – she’s a senior fellow at the Miller Center at the University of Virginia – political strategist Ron Christie and public affairs strategist Brian Wise. Thanks, you guys.

CARY: Thanks.

CHRISTIE: Thanks so much.

Copyright © 2017 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.

NPR transcripts are created on a rush deadline by Verb8tm, Inc., an NPR contractor, and produced using a proprietary transcription process developed with NPR. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.

.@SenateMajLdr just called up my amendment to put Senators on the record on whether or not they support a single-payer healthcare system.

— Steve Daines (@SteveDaines) July 26, 2017

NPR’s Robert Siegel talks with Sen. Angus King, Independent of Maine, who voted on Tuesday against an effort to start discussing a bill to reset the Affordable Care Act.

ROBERT SIEGEL, HOST:

Only two Republicans, Susan Collins of Maine and Lisa Murkowski of Alaska, broke ranks with their party in today’s vote. This vote does not repeal or replace the Affordable Care Act, but it sets the Senate on a course of discussing and perhaps amending a bill that would do just that. We’re going to turn now to a senator who voted against today’s motion to proceed, Senator Angus King of Maine, an independent who caucuses with the Democrats. And thanks for joining us once again.

ANGUS KING: Absolutely. Glad to be with you. And I got to say at the outset, I love John McCain. His statement today was just brilliant. I wish he’d voted the other way, but I think he served notice on his colleagues that he was simply voting for the procedural step to open debate and wasn’t necessarily expressing support for some further version of one of these bills.

SIEGEL: Do you love his proposal to go to the Senate health committee, return to regular order and have hearings on a health care bill that presumably committee Republicans and Democrats would both take part in?

KING: Absolutely. That’s exactly what we ought to do, Robert. I mean, that’s the way this place is supposed to work. And by the way, it’s the way John McCain’s committee work. I’m on the Armed Services Committee. We had long meetings, we had hearings – hearing after hearing after hearing. We had amendments, we had votes, we had no party-line votes within the committee. It can work that way. He’s absolutely right. That’s the way it ought to happen.

SIEGEL: But wouldn’t any bill that emerged from that process in the Senate then have to go eventually to the House of Representatives, where the Republican majority is more conservative than it is in the Senate? And wouldn’t it be a bill that ultimately you could say from the outset you’re going to vote against?

KING: Well, it depends on what happens. It depends on what the House decides. If they want to get something – and presumably, if there was a Senate bill that came out of a bipartisan process in the committee, there would be something there that the Republicans could support. If they decide they want the whole terrible consequence of kicking millions of people off of health insurance, then we aren’t going to be able to agree. But we certainly can get somewhere working in a regular way where people have a chance to get their voices heard.

SIEGEL: Can you imagine a bipartisan process by which you and Democrats give up something that you really want – say, the individual mandate – because that’s the only way to get another bill? Or is that a bright line right there that you can’t cross?

KING: Well, I don’t want to negotiate on the radio.

SIEGEL: Of course.

KING: But I do think that there are – I mean, I myself, since I got here in 2013, have been talking with a number of people about things we can improve and change in the Affordable Care Act. The Affordable Care Act is not perfect by any means. The problem is the response has been, we don’t want to fix it. We just want to repeal it, get rid of it, throw it out. We want to cut Medicaid. And if their bottom line is severe cuts to Medicaid and a major tax cut for the wealthiest Americans, then we aren’t going to get anywhere.

But if they can stop talking about repealing and start talking about fixing and really dealing with the real problems of people in our society – that’s what bothers me about this. This is about real people. This is about disabled people, elderly people in my state of Maine. And that’s why Susan Collins and I had to vote no today.

SIEGEL: Senator King, just briefly. If, in fact, the leadership, the Republican leadership, doesn’t go along with Senator McCain and sticks with this reconciliation process, do you think they have 50 votes to pass a big health care bill?

KING: I don’t think so. I think they’re going to end up a month from now exactly where they are now, and that is trying to find 50 votes for various options. I think we’ve seen three or four now, none of which could get 50 votes. They may go to the House with – they may get 50 votes on some stripped-down bill that does practically nothing and just gets them into the conference with the House. But then whatever comes back out has to go through the Senate. I think it’s very hard to get those 50 votes.

SIEGEL: Senator Angus King of Maine. Thanks for talking with us.

KING: Thank you.

(SOUNDBITE OF THE NEW MASTERSOUNDS’ “IN THE MIDDLE”)

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NPR transcripts are created on a rush deadline by Verb8tm, Inc., an NPR contractor, and produced using a proprietary transcription process developed with NPR. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.

Nurse-Family Partnership programs provide low-income mothers with checkups. Robert Siegel speaks with Nobel Laureate James Heckman on the benefits of NFP, which is found to especially help boys.

ROBERT SIEGEL, HOST:

Our next guest is a Nobel laureate, an economist who knows that providing support to new mothers means children who are healthier and more successful in life. James Heckman’s conclusions are reinforced by a new study on the effectiveness of a home visiting program called the Nurse-Family Partnership, or NFP. It supports low-income first-time mothers in 43 states. Nurses visit new mothers during pregnancy through the age of 2, showing them how to care for their babies, urging them to read to their children, to take them out and show them things. And professor James Heckman’s analysis shows that that can make a huge difference, especially for boys. Welcome to the program.

JAMES HECKMAN: Oh, glad to be here.

SIEGEL: Your paper looks at a Nurse-Family Partnership program in Memphis. It started in 1990, and it kept track of hundreds of kids who participated, tracking them until they were 12. What did you find?

HECKMAN: Well, at age 6, if you look for both boys and girls, you see both cognitive benefits – the, you know, ability to function in a classroom and to acquire knowledge and just to solve ordinary day-to-day problems – as well as social and emotional skills. That’s for both boys and girls. When you get to age 12, the primary benefit that’s lasting would be cognitive skills, cognitive skills that – for boys.

And there are benefits which are for the mother. During the period of time when the mother – looking at the first two years with the child, there does seem to be an enhanced strength of the maternal environment in the sense the mother has less anxiety. She seems better able to cope, and she herself is calmer and more maybe focused and directed towards the education of her child.

SIEGEL: But that big gender gap between boys and girls, boys still showing the benefits as you see it and as you analyze it through the age 12 – what’s the big difference here?

HECKMAN: I think we as society are beginning to understand the greater vulnerability of boys, especially disadvantaged boys, the lower levels of resilience, if you will, to adversity. Girls, for whatever reason – and I think it may be biological or it may be because of the relationship with the mother. It’s not fully understood. But girls can actually seemingly shake the adversity off. It’s not that girls aren’t affected by early adversity, but boys seem particularly vulnerable.

SIEGEL: The Nurse-Family Partnership, or NFP program, that you were analyzing was in Memphis.

HECKMAN: Yes.

SIEGEL: I’ve seen that there are similar positive effects from a similar idea in Jamaica, but that in Britain, a similar program did not show any great differences. Any idea why?

HECKMAN: Well, the British program I know less well, but the Jamaican program is a wonderful example. The Jamaican program had some of the same features, what I consider the key feature of the Nurse-Family Partnership program, which was that it encouraged mothers to interact with their children. And if you can get a chemistry going between the child and caregiver, what you’ve done is created a lifetime environment that motivates the child, that motivates the mother. And it builds a synergy which actually leads to productive children and productive families.

SIEGEL: We spoke years ago. You were talking about the value of preschool…

HECKMAN: Yes.

SIEGEL: …For kids. And in this case, what you’re describing, something very valuable, is – it’s very modest. The intervention of the nurse is, you know, somebody shows up a few times to talk with the mother. And yet that yields big results, you say.

HECKMAN: Yes. So when we boil all this down, you know, I think it’s almost like this Beatles song, you know, all it takes is love or something. It really is requiring that somebody love you. And love is a very scarce resource, of course, probably the scarcest resource in modern – in any society. But if somebody takes an interest in you – it doesn’t have to be a massive – you know, for example, in Chicago, we’ve had these home projects, now torn down, the Robert Taylor Homes – very, very infamous in their own – gangs roaming around.

But children who grew up in those have come – many of them have become very successful or moderately successful – middle class, anyway. And always the ingredient was a mother or a caregiver who was sincerely interested in the lives of the children, protected the child, encouraged the child. I think that’s what’s missing. And I think that is the love that probably is the key ingredient.

SIEGEL: Well, professor Heckman, thanks for talking with us again.

HECKMAN: OK, it was great talking to you. Have a good day.

SIEGEL: That’s professor James Heckman, economist at the University of Chicago.

(SOUNDBITE OF THE BEATLES SONG, “ALL YOU NEED IS LOVE”)

Copyright © 2017 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.

NPR transcripts are created on a rush deadline by Verb8tm, Inc., an NPR contractor, and produced using a proprietary transcription process developed with NPR. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.

NPR’s Scott Simon talks with Michael Neidorff, CEO of the health insurance company Centene Corporation, which has expanded coverage on the insurance marketplace even as other insurers have withdrawn.

SCOTT SIMON, HOST:

The debate over how to reform or repeal the Affordable Care Act might be stalled in Congress, but insurance companies are already making plans for 2018. Some insurance companies are pulling out of the Obamacare exchanges because of uncertainty about the federal government’s commitment. That means a number of so-called bare counties in Nevada, Indiana and Ohio could lose all of their marketplace plans next year. But other companies have found a way to expand coverage. Centene Corporation is one of them. Its CEO, Michael Neidorff, joins us now from St. Louis. Mr. Neidorff, thanks so much for being with us.

MICHAEL NEIDORFF: Thank you. It’s very nice to be with you.

SIMON: Do I get this right, your company has more than doubled in exchange customers in recent years?

NEIDORFF: Yes. We went from – in 2016, we had about 480,000 lives. And in ’17, we have 1.2 million at the beginning of the year.

SIMON: So what are you doing differently?

NEIDORFF: Well, I think we’re just doing our thing our way. We believe it’s a good program. We’re focused on our population, which is at the lower end of the socioeconomic scale. And it’s a matter of giving them access, having the proper networks and truly medically managing it in the most constructive way. We believe the highest quality is the most cost effective, and we’ve been doing that. And it’s working.

SIMON: But are you often alone in these areas? Are you often the only provider?

NEIDORFF: In some counties, we’re the only provider. And that’s fine because we want the very sick and the very well. We want that balanced book of business. So…

SIMON: Yeah.

NEIDORFF: …You know, being the only one does not bother us.

SIMON: Well, it’s very fine for you. But can you see where people might prefer to have more than one possibility for their health care coverage?

NEIDORFF: I am pleased when they have a choice. I can show you one county in Southern California where they have a choice. And we have 85 percent of the market, pushing 90 percent. So in fact, I like when they have a choice because it makes us look that much better.

SIMON: You, as we note, certainly seem to be doing well. But I gather you’ve said in interviews that the Senate’s health care overhaul is headed in the right direction.

NEIDORFF: Well, I felt that where they were – it needed some more tweaking. It was headed in the right direction, in the right place. And I think it’s now going to be very stalled. The parliamentarian ruled last night and was just studying all the things she said. But it’s just going to further complicate what they can get done.

SIMON: Yeah. What kind of tweaks do you think need to be made?

NEIDORFF: Oh, I was looking to put in a – what we had titled the copper plan. And this was where there was wellness, a higher deductible and then catastrophic care for the young, healthy people who tend not to buy insurance because they’re not going to need it.

SIMON: Yeah.

NEIDORFF: But when – if they had the right policy, I wanted to see reinsurance as opposed to high-risk pools. Reinsurance keeps the health plan involved on a – maybe an 80-20 basis. I’m getting a little technical on you.

SIMON: Yeah, I don’t understand reinsurance.

NEIDORFF: Well, reinsurance is where if a case goes over, let’s say, $100,000, there is a reinsurance pool within the state. They pick up 80 percent of the cost, but we still have 20 percent, which means we’ll continue to manage it. And it’s a way to handle catastrophic care without trying to rate everybody.

SIMON: Is it hard to do business, Mr. Neidorff, when you’re in your business, if – in the midst of all this uncertainty?

NEIDORFF: No, I don’t find it that way. We have taken the point of view that you make your decisions based on the facts as they are today, you know. If you do the what-ifs, you’re going to be like what Ansoff once said over in Amsterdam, analysis by paralysis, or, I should say, paralysis by analysis. And so what we do is we’re deciding, what do we have today? And we’re playing by those rules, and it’s working.

SIMON: Michael Neidorff is the CEO of the Centene insurance company. Mr. Neidorff, thank you very much for speaking with us, sir.

NEIDORFF: It was my pleasure. Thank you.

(SOUNDBITE OF TYCHO’S “AWAKE”)

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What options do Senate Republicans have left in their effort to undo the Affordable Care Act, which is also known as Obamacare? The stakes seem much bigger than just health care.

DAVID GREENE, HOST:

The only thing that appears certain in the Senate when it comes to health care is that there will be a vote next week. Senate Majority Leader Mitch McConnell made that clear after a senators-only lunch with President Trump at the White House.

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MITCH MCCONNELL: Well, it’s pretty obvious we’ve had difficulty in getting 50 votes to proceed. But what I want to disabuse any of you of is the notion that we will not have that vote next week.

GREENE: Some double negatives there, but it sounds like what McConnell is saying is that there will be some kind of vote next week. What will be voted on? Let’s ask NPR congressional correspondent Susan Davis, who has been covering this. Good morning, Sue.

SUSAN DAVIS, BYLINE: Hey, David.

GREENE: So what options are left for Mitch McConnell right now? What could they vote on?

DAVIS: There’s really three options on the table. And the first one, and the one that seems most likely at this stage, is failure. They still simply don’t seem to have the votes it takes to pass a piece of legislation. The two pieces of legislation on the table are one option that would essentially just repeal much of the Affordable Care Act in the short term and give Congress a two-year delay period to try and find something to come up with to replace it with. And then the other option is a repeal-and-replace companion, where they repeal much of the law and, at the same time, institute a new system for people to purchase insurance on the individual market.

GREENE: But this is very complicated – right? – because weren’t there senators who voted for just repeal a couple years ago but are now saying they don’t want to vote for just repeal? I mean, there’s a lot of nuance and complexity here.

DAVIS: Health care is complicated…

GREENE: (Laughter) To say the least.

DAVIS: …As our president once said. You’re absolutely right. You know, what gets some combination of moderate senators back on board is likely to knock a couple conservatives off the team and vice versa. So I think there is a deep amount of pessimism going into the vote next week, but I don’t think you can underestimate sort of the push party leaders and the White House are making to try and get there.

GREENE: What is the push? What is happening behind the scenes?

DAVIS: You know, at this stage, it’s really one-on-one meetings. We know that there’s an orbit of about four to six senators that are holdouts that have deep concerns about the bill. Vice President Mike Pence has been very personally involved, as has Seema Verma, who is the White House’s top Medicaid official. They’re trying to figure out what these senators’ concerns are and if there’s a way to get there. One option they’re looking at is putting more money back into the bill to fund Medicaid.

GREENE: Sue, the stakes here feel like they might be higher for this party than just about health care. I mean, is it a stretch to say this is sort of a pressure test on Republicans and their ability to govern?

DAVIS: That’s not a stretch at all. You know, Ted Cruz was on Fox News last night, and he talked about the stakes. And this is what he had to say.

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TED CRUZ: If we get this right – if we follow through on Obamacare repeal, it sets this up for this to be the most productive Congress in decades, whereas if we’re paralyzed, we could blow an historic opportunity. I don’t want us to blow this opportunity.

DAVIS: When he talks about blowing the opportunity, the concern I hear the most from Republicans on Capitol Hill is that if health care collapses – if they cannot deliver on what has been their signature campaign promise, the infighting and the bad blood that it will generate will make it almost impossible for Republicans to move forward on their other legislative priorities. That includes overhauling the tax code and that long-promised infrastructure bill that the president and Republicans and some Democrats in Congress say that they want the most.

GREENE: All at a time, of course, when Republicans have both the White House and Congress, so a lot of pressure on them to actually govern. NPR’s congressional correspondent Susan Davis in our studios this morning – Sue, thanks.

DAVIS: Thank you.

Copyright © 2017 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.

NPR transcripts are created on a rush deadline by Verb8tm, Inc., an NPR contractor, and produced using a proprietary transcription process developed with NPR. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.

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