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The House of Representatives will vote on the American Health Care Act, the bill to repeal and replace Obamacare, on Thursday in the early afternoon. House Republicans are hurtling toward a vote on a bill that is disliked by most Americans, opposed by nearly every major health care group, and not yet scored by the Congressional Budget Office. 

This is an unusual situation, and a puzzling one. Republicans will vote tomorrow for a health care bill without knowing how many people it covers or how much it would cost. They risk setting themselves up for embarrassment when the numbers actually do come out and don't look good. 

As leadership scrambles to whip the votes for the American Health Care Act, it's worth stepping back to ask: What the heck is the rush?

The best explanation I've found comes from my colleague Andrew Prokop. When Republicans started this year, they had a strategy to move two big policy packages, one on health care and another on tax reform. There would only be two chances to use the budget reconciliation process that allows a bill to pass with only 51 Senate votes (for complex procedural reasons explained here), so each would get one shot. 

Health reform would go first, they thought, because it would be simpler. It was a legislative strategy built when the Republican health care plan looked markedly different:

They thought it would be legislatively easier to write an Obamacare repeal bill than tax reform, because they intended to put off the hard work of creating an actual replacement for Obamacare until later. This was the “repeal and delay” strategy — pass a quick repeal, set it to go into effect in a few years, and write the replacement in the meantime.

But then GOP leaders encountered a problem. Their members, in both the House and the Senate, turned out to really hate the “repeal and delay” strategy, because it meant getting rid of Obamacare and its benefits without the “replacement” the party had long promised they’d offer being ready.

Republicans want to move quickly on health care so they can fit in tax reform too, another immense and complex policy lift.

Adding to that pressure, it's also the case that this current frenzy began as Trump was nearing his 100th day as president and pressuring Congress to schedule a vote. Although the 100-day mark has come and gone, some of that residual momentum seems to have hung around. 

This all explains why, in general, there is a desire to move relatively quickly. 

The part that Republicans haven't explained: Why move so quickly that they don't get a score from the Congressional Budget Office?

A legislator deciding whether or not to support the American Health Care Act would likely wonder what the bill actually does. This is the role CBO has traditionally played, providing nonpartisan estimates of who would gain coverage, who would lose it, and how much the whole thing would cost. 

The whole point of CBO scoring is to figure this out before you decide whether a piece of legislation is good or bad. This also gives legislators some space to make changes to parts of a bill that don't seem to work. CBO scores are meant to be a tool for legislators, a way to game out the consequences — both politically and policy-wise — of moving laws forward. 

It's notable that we haven't heard one member of Congress say, "I like the idea of this bill, but I'll wait until we see the CBO score to make up my mind." 

But so far, the CBO score has been treated as unnecessary — certainly nice to have, but not a prerequisite for holding a floor vote. Here's how Rep. Fred Upton (R-MI) put it earlier today to a reporter:

There are very few people telling Republican legislators at this point that the American Health Care Act is a good bill. Basically every health care interest group you can think of – hospitals, doctors, insurers, patients — don't support it. The most recent polling data finds most voters don't like it either. There is not a CBO score that suggests this bill achieves House Republicans' objectives. 

At this point, Republicans seem more concerned with moving something out of their chamber than they do with what that something is. That is a risky and potentially embarrassing move. The CBO score will come out sooner or later, and Republicans might be faced with defending a bill they don't like much at all. 

Meanwhile, in Iowa: insurer threatens to leave 94 of 99 counties with no Obamacare insurer

The health insurance plan Medica announced Wednesday that it was considering pulling out of Iowa's insurance marketplace. It is the only insurer signed up to sell coverage in all the dark pink areas of the map below, from Margot Sanger-Katz at the New York Times:

In a statement, Medica said the uncertainty in Washington makes it difficult to commit to sticking with the marketplaces in 2018:

Without swift action by the state or Congress to provide stability to Iowa’s individual insurance market, Medica will not be able to serve the citizens of Iowa in the manner and breadth that we do today. We are examining the potential of limited offerings, but our ability to stay in the Iowa insurance market in any capacity is in question at this point.

It's hard to know how much of a bellwether Medica is for the rest of the Obamacare marketplaces. On the one hand, all insurers are frustrated that Congress likely won't be appropriating funding for the cost-sharing reduction subsidies.

On the other hand, Iowa seems to be a bit of an exceptional situation. There is one patient in the marketplace who reportedly has $1 million in monthly claims (you can read more about the situation here). This has made the entire state an undesirable market for health plans, which know that if they're the last man standing, they will end up with that extremely high-cost patient. 

Kliff’s Notes

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

Today's top news

• "Key Republicans Long, Upton say they now support Obamacare repeal with more money for pre-existing conditions": “Two key Republican lawmakers say that they will support a bill to repeal and replace Obamacare after changes were proposed to provide additional funds for people with pre-existing conditions. Republican Reps. Fred Upton of Michigan and Billy Long of Missouri announced their decision to reporters outside the White House Wednesday after meeting with President Trump about the legislation.” —Kimberly Leonard, Washington Examiner
• "No good GOP options if Obamacare repeal fails": “If their latest Obamacare repeal efforts fail, Republicans really only have a few options. And each means political peril for President Donald Trump and Republican congressional leaders. House members made progress Wednesday on the repeal and replacement bill — but there are still many hurdles, including overcoming some of the same challenges in bringing together conservatives and moderates if the bill reaches the Senate.” —Adam Cancryn and Paul Demko, Politico
• "Insurer Aetna Posts Loss, Evaluates Obamacare Exposure": “Aetna Inc reported a quarterly net loss on Tuesday related to costs from its failed acquisition of Humana Inc and said it will cut exposure to money-losing Obamacare coverage in 2018. Like other U.S.-based health insurers including Anthem Inc and Molina Healthcare Corp, Aetna faces deadlines to file 2018 plans but is uncertain about components of premium rates such as the continuation of government subsidies and the mandate for Americans to have insurance.” —Reuters

Analysis and longer reads

• "Why Democrats secretly want an Obamacare repeal vote": “Democrats don’t actually want the law repealed. Under their dream scenario, House GOP leaders would muscle through their controversial health care bill only to watch it die a long, painful death in the Senate, where it has already received a lukewarm reception from Republicans. Obamacare would stay intact while the House Republicans who voted to gut the law have a big shiny target on their back heading into the 2018 midterms.” —Heather Caygle, Politico
• "Personal Tragedy Drives Deal-Making GOP Congressman on Health Care": “Since the Republicans' failed attempt to repeal and replace the Affordable Care Act, [Rep. Tom] MacArthur has nearly single-handedly breathed new life into an effort that could culminate in a vote on the GOP measure this week. But while the fight over health care has played out as political high drama in the halls of power in Washington, for MacArthur it's also a personal battle stemming from the loss of his 11-year-old daughter nearly two decades ago.” —Leigh Ann Caldwell, NBC

"As patients take hospital bill issues public, hospitals take stock of their practices":“Recently, four hospital systems in Colorado — Centura Health, Health One, SCL Health and UCHealth — found themselves on the defensive after 9News, based in Kusa, ran a piece that was critical of their billing practices. The news station had invited viewers to email copies of their medical bills to give reporters an idea of what consumers were dealing with when it came to their bills. The station then invited the four health systems to their newsroom to answer on-air questions based on patients' complaints.” —Jeff Lagasse, Healthcare Finance