Senate Republicans are set to unveil revised legislation Thursday to roll back the Affordable Care Act, even as political support has deteriorated so dramatically that it is now unclear whether GOP leaders even have enough votes to formally open the debate next week.
Senate Majority Leader Mitch McConnell (R-Ky.) has been meeting behind closed doors with Republicans to adjust the legislation after he was forced to abandon a vote last month amid a revolt within his own party. The earlier version would have left 22 million more Americans uninsured and has been vehemently opposed by leading doctor, patient and other healthcare advocacy groups.
But the new versions — there may be two revised bills presented Thursday — appear to have done little to resolve differences between the GOP’s conservative and centrist factions. And passage remains seriously in doubt.
“I can’t tell you we’re going to pass this bill,” Sen. David Perdue (R-Ga.) told reporters Wednesday.
President Trump appears to have little sway over senators, except to suggest Congress should not recess for August without delivering on the GOP campaign promise.
He told Christian Broadcasting Network founder Pat Robertson in an interview that aired Wednesday that he wants Congress to send him a bill to sign.
"I will be very angry about it and a lot of people will be very upset,” Trump said. Referring to McConnell, Trump added, “Mitch has to pull it off. He's working very hard."
But senators exiting a closed-door lunch meeting Wednesday worried GOP leaders didn’t have the 50 votes needed from their 52-seat majority for a procedural vote to start debate of the healthcare bill on the Senate floor.
McConnell has indicated he intends to push ahead once the nonpartisan Congressional Budget Office has reviewed the revised legislation. The agency’s estimates are expected Monday.
Sen. Ted Cruz (R-Texas), who has demanded that the bill further loosen requirements on health plans, remained optimistic of passage, even though he indicated he would not support opening the debate unless his proposed revision was included in the new text.
“I believe we can get to yes and we can bring together 50 senators behind Obamcare repeal,” Cruz said.
McConnell's original bill, known as the Better Care Reconciliation Act, would repeal most of the mandates and taxes in the current law, wiping out revenue that has been used expand healthcare coverage to more than 20 million previously uninsured Americans.
The Senate bill would also slash more than $700 billion from Medicaid, forcing states that expanded coverage under Obamacare to either come up with their own funds or curtail care. And it would scale back funding that helps other Americans buy commercial health plans on insurance marketplaces created by the law.
But conservative senators still complain the bill does not go far enough toward repealing Obamacare — Sen Rand Paul (R-Ky.) calls it “Obamacare light.” And the revisions will not help win their votes, particularly the emerging plan to retain two Obamacare taxes — a 3.8% investments tax and a 0.9% payroll tax — on high-income earners.
At the same time, centrist Republicans like Sen. Susan Collins of Maine worry the cuts to Medicaid will be devastating. Alaska Sen. Lisa Murkowski, another Republican who has been critical of the Medicaid cuts, called the push to roll back the program “fundamentally wrong” in an interview with the Alaska Dispatch News.
Thus far, McConnell has done little to revise the Medicaid cuts to win their votes, even as polling shows the Medicaid retrenchment is deeply unpopular.
Fewer than 1 in 10 Americans surveyed in a new poll by the American Cancer Society Cancer Action Network said they wanted to cut Medicaid; cutting it is a centerpiece of the House and Senate Republican healthcare bills. By contrast, 41% said they wanted to increase Medicaid funding and 47% wanted to keep it at current levels.
McConnell has been trying to bridge the divide in his caucus with other revisions to appeal to both camps. But the changes may not be enough.
One of the bills to be presented Thursday is expected to include Cruz’s provision to allow insurance companies to offer bare-bones plans that do not include the full set of currently required benefits, such as maternity care and treatment for mental illness and substance abuse.
Conservatives say the change will drive down premium costs for consumers.
But critics say Cruz’s plan essentially does away with Obamacare’s protections for patients with preexisitng medical conditions by allowing insurers to charge high rates to sick people who need more extensive insurance coverage and leaving everyone else with skimpy, if cheap, plans that provide inadequate coverage.
While Cruz’s plan has been pushed by the White House and has backing from conservative partners, other senators are not on board.
Several senators, including Sen. Bill Cassidy (R-La.), a physician, have been working on alternatives to Cruz’s approach. And some said they wanted to see how much savings the plan would produce for consumers.
On Wednesday, 13 patient groups — including the American Heart Assn., the American Lung Assn., the March of Dimes, AARP and the American Cancer Societys’ advocacy arm — sent senators a strongly worded letter lambasting Cruz’s proposal.
The groups call the proposed amendment “a betrayal of the commitment to protect Americans from price discrimination based on a preexisting health condition.”
Even health insurers, many of whom have remained largely quiet about the current healthcare debate, blasted the Cruz proposal, warning it would destabilize insurance markets around the country.
A second version of the bill is likely to leave the Cruz provision out, but will include other changes aimed at wooing other GOP holdouts, including $45 billion for states to address the opioid crisis. That was a top concern of Sen. Rob Portman (R-Ohio) and Sen. Shelley Moore Capito (R-W.Va.).
Whether the money will be enough to resolve senators’ concerns over the Medicaid cuts remains unclear, however.
Ohio Gov. John Kasich, a Republican who has been outspoken about the need to retain Medicaid coverage, has compared the proposed opioid funding to “spitting in the ocean.”
The new bill is also expected to include a provision to expand the ability of Americans who sock away money in tax-deferred Health Savings Accounts to pay their insurance premiums from those funds.
Senate Republican leaders have been almost pleading with their colleagues not to derail this effort. Failure to pass the bill, after a similar version has already cleared the House, would leave Republicans with few big-ticket accomplishments for their hold on Congress and the White House, which is especially problematic since they campaigned for years on the promise to end Obamacare.
Senators are being promised a chance to further amend the bill once they open debate next week. But some are skeptical the changes they want to make will be backed by the majority for inclusion.
Sen. John Cornyn (R-Texas), the GOP whip, urged colleagues to at least open the debate and start the process.
“It's not perfect,” he conceded about the bill. “So I would urge all of our colleagues to work with us in good faith to try to improve it.”