Ryan bets on second bill to woo the reluctant

House Republicans are working on a companion to their bill replacing "Obamacare," a legislative second act that would ease cross-state sale of health insurance and limit jury awards for pain and suffering in malpractice lawsuits.

The problem: the so-called "sidecar" bill lacks the votes in the Senate.

Skeptics abound. Republican Sen. Tom Cotton of Arkansas called it "mythical legislation" in an interview Tuesday on the Hugh Hewitt radio show. In a tweet, conservative Rep. Thomas Massie, R-Ky., suggested "Easter basket" might be a better description.

Yet Speaker Paul Ryan, R-Wisc., has said he wants to move a companion bill through the House alongside the main GOP legislation that rolls back key parts of Barack Obama's healthcare law and limits federal spending on Medicaid for low-income people.

That strategy may just help Ryan put together enough votes to get through the House, but then the sidecar would probably get detached in the Senate, where 60 votes would be needed for such legislation. Republicans only have 52 senators and they would need the support of Democrats alienated by the drive to repeal "Obamacare."

"Some of these ideas might take some of the edge off the (main) bill for people on the right in the Republican Party," said economist Joe Antos of the business-oriented American Enterprise Institute. "I don't know that it can possibly overcome the Senate problems."

At a news conference Tuesday, Senate Minority Leader Chuck Schumer, D-N.Y., said Democrats will not support any legislation reshaping the healthcare law until Republicans stop trying to repeal it. If Republicans desist, Democrats would be willing to talk.

Schumer later said he isn't keen on the idea of a House companion bill. "They probably have ideas that would make it worse," he said.

Cutting regulations and spurring private market competition are the main goals behind the GOP's idea for a companion bill. Experts say that while some of the proposals sound appealing, they also have practical problems. No final decisions have been made, but here's a look at some proposals that might be in the "sidecar."

Selling insurance across state lines is a longtime GOP idea now embraced by President Donald Trump as a way to encourage competition by introducing low-premium plans into high-cost areas. Consumer advocates and state regulators warn that would set off a "race to the bottom" as out-of-state insurers flood the market with skimpy plans that circumvent state requirements, for example New Jersey's mandate for autism coverage.

But the idea also gets a surprisingly cool reception from the insurance industry. Why?

It turns out that the price of health insurance, like real estate, reflects local markets. An insurer from Kansas selling policies in Manhattan would have to pay hospitals and doctors in New York according to local rates. Also, building networks of service providers that are attractive to consumers is no easy task for insurers.

Republicans have long advocated capping jury awards for non-economic damages in medical malpractice cases, and $250,000 is a commonly cited limit. The Congressional Budget Office has previously estimated such caps would reduce healthcare spending by limiting the practice of defensive medicine.

The $250,000 reflects a limit that California imposed in 1975. Adjusted for inflation, that figure would now be over $1 million.

The debate pits two powerful lobbies — doctors and lawyers — against each other. So far the lawyers have gotten the upper hand in Congress.

A criticism of malpractice limits is that they fall hard on those who have suffered the most egregious damage and are likely to face lifetime expenses, for example the family of a brain-damaged infant.

Small businesses would be able to band together to arrange to buy lower-premium plans tailored to their needs.

The debate around association health plans echoes the one over cross-state insurance policies.

Advocates say their idea would provide a way around regulations that raise the cost of health insurance. But consumer advocates and state regulators say it would undermine protections for patients and undercut state oversight of the insurance industry.

A 1940s federal law offers the insurance industry a qualified exemption from federal anti-trust laws. Proponents of repealing the exemption say it is a barrier to competition. In the past, that idea has had bipartisan support in Congress, but it's unclear what would happen now with the two political parties bitterly divided over healthcare.

Other ideas being discussed among Republicans may also make it into the sidecar legislation.

But they all seem headed for a roadblock in the Senate. Within the administration, Health Secretary Tom Price is working to loosen regulations.

"The chances that they are going to pass this hodgepodge in a separate bill is pretty much between slim and none," said Bob Laszewski, an industry consultant and blogger. "You are not going to get Democratic support for these things."