WASHINGTON — Senate Republican leaders on Thursday moved swiftly to begin selling their health-care measure to substantially rewrite the Affordable Care Act to their wary members as they seek to garner enough support to pass the bill in an expected vote next week.
Judging from the early signs of reaction from Republican senators, the bill's future is in serious doubt moving forward.
Senate Majority Leader Mitch McConnell, R-Ky., — who spearheaded the crafting of the legislation behind closed doors in recent weeks - distributed a draft copy of the sought-after legislative text to his Republican rank-and-file in a private meeting on Thursday morning.
But the fact that it would preserve key requirements under the existing law has angered senators on the right, such as Mike Lee, Utah, Rand Paul, Ky., and Ted Cruz, Texas, whose votes will be critical to passage. Meanwhile, the measure's plan to end generous federal funding for a Medicaid expansion that has covered roughly 11 million Americans has given more moderate Republicans pause.
According to two Republicans in close contact with Senate GOP leadership granted anonymity to describe private conversations, McConnell is threatening to bring the bill to a vote next week even if he doesn't have the votes to pass it. But some believe that message is aimed at trying to pressure Republicans to support the bill rather than an absolute commitment - and that the majority leader would end the push if he doesn't have the votes. A McConnell spokeswoman declined to comment.
For now, the Kentucky Republican is forging ahead.
"Right now the challenge is how we get to 50," said Sen. John Thune, R-S.D., a top McConnell deputy, referring to the number of senators needed to pass the bill, with Vice President Mike Pence standing ready to cast a tiebreaking vote.
No Democrats are expected to support the measure, which dramatically scales back the 2010 Affordable Care Act that was President Barack Obama's signature domestic achievement and helped ensure coverage for roughly 20 million Americans through a combination of Medicaid coverage and subsidized private plans.
One potentially ominous sign for leadership was the reaction of Nevada Sen. Dean Heller, R, who is up for reelection in 2018. Heller released a statement saying he has "serious concerns" about the bill's Medicaid provisions.
The 142-page bill would curtail federal Medicaid funding, repeal taxes on the wealthy and eliminate funding for Planned Parenthood as part of an effort to fulfill a seven-year promise to undo Barack Obama's signature health-care law.
It abolishes two of the law's central mandates — that individuals must show proof of insurance when filing their taxes, and that firms with 50 workers or more must provide health coverage — while providing less money for moderate and low-income Americans buying insurance on the individual market.
The bill is an attempt to strike a compromise between the ACA and a measure passed by the GOP-controlled House in May. The Senate proposal largely mirrors the measure that passed the House — with some significant differences.
"Republicans believe we have a responsibility to act — and we are," said Senate Majority Leader Mitch McConnell, R-Ky., in on speech on the Senate floor. He underscored the taxes and regulations in the ACA that the GOP measure would repeal.
Senate Democrats swiftly protested the bill, criticizing Republicans for crafting it under very secretive conditions and asking for more time to debate and vet the measure than McConnell plans to allow. Minority Leader Charles E. Schumer, D-N.Y., said Republicans were "turning truth upside down" with their promises of an open amendment process next week.
But McConnell faces the prospect of an open revolt from key conservative and moderate GOP senators, whose concerns he has struggled to balance in recent weeks. Senate leaders have more work to do to secure the votes needed to pass the measure, Republicans familiar with the effort said.
Republicans only need 50 out of the 52 Republican votes in the Senate if they rely on Vice President Pence to cast a tie-breaker.
Many GOPers reserved judgment on the measure as they exited McConnell's private presentation. In the days leading up to the bill's release, some Republicans have intensified their complaints about the substance of the emerging bill and the tightly controlled process under which McConnell and only a small handful of aides wrote it.
Sen. Tim Scott, R-S.C., said the mood in the room made for an "interesting morning, a little tense." He was one of several Republicans who pushed for the Senate measure to be "more gracious" than the House bill, an aim he feels was satisfied. But Scott predicted there was "a long way to go" before concluding whether it could pass.
Senate leaders plan to move the bill to the floor after receiving an analysis from the nonpartisan Congressional Budget Office, which said Thursday it will do "early next week." The CBO is expected to release a comprehensive estimate of how many people are expected to lose coverage as a result of the bill and how much it is expected to cost.
The CBO concluded the House bill would leave 23 million more Americans uninsured by 2026 than under current law, while also concluding that premiums would drop overall.
Like the House bill, the Senate measure would make big changes to Medicaid that in effect would reduce federal spending on the program. The Senate measure would cut off expanded Medicaid funding for states more gradually than the House bill by phasing out the higher federal match between 2020 and 2024, but would enact deeper long-term cuts to a program that provides health care coverage for 74 million Americans.
It also would eliminate House language aimed at prohibiting federally subsidized health plans from covering abortions, a provision that may run afoul of complex Senate budget rules.
While the House legislation would peg federal insurance subsidies to consumers' age, the Senate bill would factor in income as well, as the ACA does. But younger people would still get more generous subsidies than they do under current law.
The measure would preserve two of the ACA's most-popular provisions: insurers could not deny coverage based on preexisting conditions and children may stay on their parents' plans until the age of 26. Insurers must set prices based on the overall insurance pool rather than charging sicker Americans more.
But the bill would allow states to use an existing ACA program, known as 1332, for states to file waivers with the Centers for Medicare and Medicaid Services to scale back what sort of plans insurers offer. Through these waivers states could eliminate elements of the ACA's essential health benefits package, which includes preventive and maternity as well as newborn care, along with substance abuse and mental-health treatment. Such changes would make plans cheaper, though they could lead to higher out-of-pocket expenses for consumers.
Insurance subsidies are currently available to Americans earning between 100 percent and 400 percent of the federal poverty level. Starting in 2020, that threshold would be lowered to 350 percent under the Senate bill — but anyone below that line could get the subsidies if they're not eligible for Medicaid.
In a move that will please the health-care industry, the Senate bill also proposes repealing all the ACA taxes except for its "Cadillac tax" on high-cost health plans in language similar to the House version. Senators had previously toyed with the idea of keeping some of the ACA's taxes.
It would also eliminate Medicaid reimbursements for Planned Parenthood for one year. Federal law already prevents taxpayer funding to pay for abortions except to save the life of the mother or in the case of rape or incest. But some Republicans want to ban all federal funding for Planned Parenthood, which also provides health services such as birth control and preventive screening.
In a move that is critical to insurers, the Senate measure would continue to fund for two years cost-sharing subsidies that help 7 million Americans with ACA plans. House Republicans have challenged the legality of the $7 billion in subsidies - which help cover consumers' deductibles and copays - in court, and insurers warned they would have to increase premiums dramatically next year unless the federal government commits to continuing the payments.
Outside criticism of the GOP effort has been mounting. The heads of 10 managed care organizations penned a letter to McConnell and Schumer this week saying they were "united in our opposition to the Medicaid policies currently being debated by the Senate."