WASHINGTON — Republican negotiations over how to overhaul the Affordable Care Act centered sharply Thursday on a divisive and ideological question: How much money should the Senate health-care bill spend on protecting vulnerable Americans, and how much on providing tax relief to the wealthy?
Senate Majority Leader Mitch McConnell, R-Ky., in an effort to strike a balance between centrists and conservatives, is now making concessions to both factions of his caucus, according to lawmakers and aides.
McConnell is rewriting his proposal to provide tens of billions more for opioid treatment and assistance to low- and moderate-income Americans, in part with a major policy shift that has already alarmed conservatives who oppose it: by potentially preserving a 3.8 percent tax on investment income provided under the Affordable Care Act that the current draft of the Senate bill would repeal.
At the same time, the Republican leader hopes to placate the right by further easing the existing law's insurance mandates and providing higher tax deductions for the health-savings accounts that conservatives favor, several Republicans said.
By Thursday afternoon, Senate leaders had agreed to dedicate $45 billion to opioid funding, GOP aides told the Washington Post — a concession that Sens. Rob Portman, R-Ohio, and Shelley Moore Capito, R-W.Va., had been seeking for weeks. The draft released last week included only $2 billion.
It remains unclear whether these changes, if adopted, would garner enough support for the bill to pass. But they may represent the most viable path forward if Republicans want to rewrite the 2010 health law known as Obamacare without any help from Democrats.
"We will, it appears to me, address the issue of ensuring that lower-income citizens are in a position to be able to buy plans that actually provide them appropriate health care," said Sen. Bob Corker, R-Tenn. "And with that, my sense is that the 3.8 percent repeal in the current draft will go away."
In a sign of the sharp disagreements that continue to plague Senate Republicans, Sen. Patrick J. Toomey, R-Pa., disputed Corker's notion that the tax cut would be jettisoned, calling the proposal a "very bad idea."
"I'm not at all convinced that that's where it's going," Toomey said.
The 3.8 percent tax applies only to individuals making over $200,000 a year, and married couples earning more than $250,000. Repealing it as of Dec. 31, 2016, as the bill does now, would cost the federal government $172 billion in revenue over the next 10 years, according to a recent CBO analysis.
The effort was complicated by the release of a new Congressional Budget Office estimate that showed significantly deeper reductions in Medicaid spending after the legislation's second decade than at the end of its first decade. The new analysis specifically looked at the legislation's effect in its second decade, adding to an analysis of the first decade released at the start of the week and showing that 22 million fewer Americans would be covered by 2026.
By 2036, the new analysis said, the government would spend 35 percent less on Medicaid than under the current law, compared with a 26 percent decrease in the first decade.
The updated Medicaid estimate from the CBO, showing how spending would shrink over the next 20 years, underscored the extent to which McConnell's plan would squeeze the longstanding public insurance program. The current draft already cuts $772 billion over 10 years from Medicaid, which covers poor and disabled Americans as well as the elderly, children and pregnant women.