ASHINGTON — Louisiana’s senior senator, a former liver doctor, has practiced medicine for decades.
Bill Cassidy has taught medical students; led efforts to vaccinate thousands of Louisiana schoolchildren; founded a community clinic that pairs uninsured patients with doctors willing to treat them; and after Hurricane Katrina helped to transform an abandoned Kmart in Baton Rouge into a makeshift hospital wing.
The first-term Republican has effectively spent his career on health care. Now, for the first time in his political life, with Republicans in control of Washington and intent on replacing Obamacare, he’s in a position to play a pivotal role in reforming the nation’s heath care system.
There’s just one problem: When it comes to health policy, Republican leaders don’t seem to want him in their inner circle.
Bill Cassidy doesn’t seem to care.
“I don’t think I have to be in the room,” he said in an interview with STAT.
The room is a 13-member group of Republicans, led by Majority Leader Mitch McConnell, tasked with rewriting a bill that could reshape the nation’s health insurance system.
Cassidy is one of the group’s more notable exclusions. He has a public health track record unmatched in the Senate, and, along with Senator Susan Collins of Maine, he has authored a health reform bill that bears little resemblance to the one passed by the House two weeks ago.
With Collins, he is also leading what is effectively a shadow group to McConnell’s original band of 13. Unlike the GOP leadership’s group, Cassidy’s includes women — and it includes Democrats. It met for the first time on Monday evening.
Together, the group seems to be making strides, or at least engaging in real, bipartisan debate.
“It’s never a bad thing when you’re discussing these issues with a variety of senators,” said Senator Dan Sullivan of Alaska, a Republican. “Especially smart ones who know they’re talking about on these issues, right?”
While none of the group’s members was sure if the meeting would become a recurring event, they said it has served as a forum for members to introduce concepts outside the mainstream.
Senator Lindsey Graham of South Carolina, a Republican, said he took advantage of the opportunity at the first meeting to present his own idea. Graham suggested taking the “four or five major drivers of health care cost,” like diabetes or kidney failure, and placing patients with those conditions in a version of a high-risk pool, which would be federally managed.
“If you took that 5 percent of the patient population that spends 50 percent of the money because of very serious, chronic illnesses, and you say this is going to be a federal government obligation, partnership with the patients, partnership with the private sector, but a managed care system, then it makes it so much easier for the private sector to flourish,” he said.
As with most congressional conversations lately, amid a flurry of news from the White House, the idea was presented hurriedly to reporters on Tuesday. But Graham claimed that it piqued the interest of the three Democrats present, which Senator Heidi Heitkamp of North Dakota confirmed.
“I think everybody was intrigued,” she said. “I said I’d love to hear more about funding and what the idea is.”
Despite the apparent disconnect between McConnell’s group and Cassidy’s, some GOP senators have disputed the idea that more health care influence is being wielded inside the group than out. Republicans typically lunch together three times each week, and McConnell has said that, of late, health care is the dominant topic.
Cassidy said he felt confident his policy ideas had a presence in McConnell’s group, adding that as of Tuesday, McConnell had let all Republican members know they could “start coming as they wish.”
“The way the leader is running it, everybody is included,” said Senator John Neely Kennedy, a Republican and Cassidy’s Louisiana counterpart, who also is not a working group member. “We’re spending an hour and a half per day where everybody gets to offer their input.”
Yet on paper and in closed-door meetings, the disconnect remains. Of the six Republicans whose names appear on the Cassidy-Collins bill, none was invited to join McConnell’s working group.
The leadership’s brush-off notwithstanding, Cassidy is unshakably confident that a version of his bill — the foundation for some of the shadow group’s discussions — is the inevitable solution.
That bill would allow states to design their own health insurance programs, or, if they choose, re-impose many Obamacare restrictions like the individual mandate and essential health benefits requirement. It would also maintain the ACA prohibition on coverage denials due to pre-existing conditions, provided consumers avoid substantial coverage gaps.
Cassidy is not shy about pushing the legislation. The top of his official Senate website is just a bright red bar with the text: “Alert: Click Here to Read the Patient Freedom Act of 2017.” He also does not hesitate to bring up his career in medicine, or his belief that health care providers have an inherently better understanding of health care policy — and that his family is an especially good example.
“How could it be otherwise?” he said of medical practitioners’ innate expertise. “But I will say, some of the best economists have a way of quantifying it — but it is so counterintuitive that you really either need to be a health care provider or you need to be an economist who really thinks about it.”
Citing the work of Princeton economist Uwe E. Reinhardt, Cassidy stressed that physicians don’t need to be paid “an arm and a leg,” but in a stance common among physicians railed against cutting Medicare reimbursements as the Affordable Care Act did in 2011, which he said end up costing the market more money in the long run.
Despite his wonkiness — at one point during the interview, he exclaimed, “I wish I had a whiteboard!” — Cassidy has also mastered the tone of selling his plan to the voters who will benefit from it even if they’re unaware of its finer points.
“Under the Cassidy-Collins plan, you would continue to get help,” he said to a make-believe Medicaid recipient as he play-acted a congressional town hall. “I’m a physician; I’ve worked for 25 years in hospitals for the uninsured; I know exactly what you’re saying.”
But merely possessing a Medicaid card, he said, is more symbolic than it is effective. It was his proposal in 2013, Cassidy noted, that first proposed per-capita caps on Medicaid spending — now a standard element of most Republican health proposals.
Cassidy and his family were known for their medical practice, and their efforts at charity hospitals and community clinics, before his election to Louisiana’s state senate in 2006.
Cassidy met his wife, Laura, at a Los Angeles Bible study group when he was completing a fellowship in gastroenterology at the University of Southern California; she was a resident in surgery across town at the University of California, Los Angeles. Laura Cassidy, too, has spent time in charity hospitals, and remembers patients whose care was otherwise uncompensated, bringing her meals in lieu of money.
Together, they speak health policy with a fluency better than perhaps any other congressional family.
The decision to leave Cassidy out of the working group also left the family’s friends in Louisiana more bemused than angry. Not everyone in Baton Rouge agrees with his politics, according to the pastor at the campus chapel the family attends near LSU, but nobody questions his compassion.
“He has spent his whole life dealing with these issues,” said the pastor, Kevin McKee.
A few days after late-night host Jimmy Kimmel savaged the House bill while telling his audience about his infant son, who was born with a heart defect, Cassidy was invited on to his show as a guest. He was a logical choice — effectively a reasoned voice to play cleanup.
But Cassidy demurred when asked if Democrats are winning the debate simply by making Republicans seem callous on matters of health care.
Middle-class families unable to pay high individual-market premiums, Cassidy told STAT, are “where the empathy deficit might break in favor of Republicans.”
Moreover, Cassidy is fascinated by the fact that counties hardest hit by the opioid crisis are often the counties that voted by the widest margins for President Trump in November.
“Being non-college-educated, having so few options in life, they were turning to self-destructive behavior,” he said. “I actually think Trump, on the campaign trail, recognized that. He spoke specifically about opioid addiction as a need to care for. I think they saw Trump’s statements as a lifeline, and their vote was a cry for help. Trump won because these folks, who traditionally voted Democrat, voted for him.”
Cassidy was referencing, in part, the president’s stated desire to provide “insurance for everybody.”
A recent poll, however, showed that barely 1 in 5 Americans, consistent across demographic groups, approved of the American Health Care Act as passed by the House.
No polling exists on Cassidy’s bill, but despite the raw numbers, he seems to view Obamacare repeal as the ticket to Trump’s reelection in 2020, and he sees his own legislation as the ticket to Obamacare repeal. Therein lies the sell he’s begun to make.
“The more folks understand that the Trump voter is the one who’s benefiting from this, and the Trump voter will be the one who disproportionately is harmed if we do it poorly,” Cassidy said, “hopefully they’ll understand that it’s incumbent upon us to fulfill Trump’s campaign pledge.”