For more than seven years, Republicans have been promising voters they would repeal the Affordable Care Act. The bill that GOP senators unveiled on Thursday is very far from that promise.
Yes, some Obamacare measures are out, like the individual and employer mandates. That’s a big one for conservatives who don’t believe government should force them to buy – or offer, in the case of employers – health insurance.
The bill also phases out the ACA’s expansion of Medicaid that 31 states and Washington, D.C., have used to cover more low-income Americans. That’s an attempt to rein in federal spending, another conservative goal. The bill even goes beyond repeal by eventually ending the open-ended guarantee of federal funding for the entire Medicaid program.
Still, “we’re a long way from repeal,” says G. William Hoagland, senior vice president at the Bipartisan Policy Center, speaking about the bill that – if it passes the Senate (a big if) – could end up as the law of the land. The reason for that great distance, he says, is that it’s hard to claw back benefits that have already been conferred on millions of people.
So, what has emerged after more than 60 repeal attempts under President Obama, and six months of GOP control of the White House and Congress, is a Republican plan that keeps the broad structure of Obamacare: the marketplace exchanges where individuals purchase insurance; the healthcare benefits for those who want them, and many of the taxes and subsidies – though in different forms – to support that structure.
“I promised to repeal Obamacare, not to continue Obamacare,” Sen. Rand Paul (R) of Kentucky told “Fox & Friends” on Thursday morning. He opposes the bill.
Procedural and political constraints
Procedurally, Republicans are in a tough spot on repeal because they don’t have the 60 seats in the Senate to overcome a Democratic blocking filibuster. To pass it on their own, they have to abide by Senate rules that limit their work to tackling those parts of Obamacare that directly relate to the federal budget – such as striking the fines associated with the mandates, instead of the mandates themselves.
But politically, “it’s very hard, once you’ve created an entitlement, to take it away or even reform it,” says Matt Mackowiak, a Republican consultant in Austin, Texas.
That's why the GOP mantra of “repeal and replace” has proved so difficult for Senate majority leader Mitch McConnell (R) of Kentucky. He's been trying to find the sweet spot that will bring at least 50 Republicans to “yes” (with Vice President Mike Pence providing the tie breaking vote).
Last month Senator McConnell tried, and failed, to find that sweet spot, and had to pull the bill for lack of support from both conservative and moderate Republicans. At least 10 Republicans opposed the bill.
Revised to woo skeptical GOP senators
This revised version tries to appeal to the conservative wing by tentatively including changes based on an amendment by Sens. Ted Cruz of Texas and Mike Lee of Utah that would allow insurers to sell no-frills insurance as long as one of their plans adheres to the requirements of Obamacare – including its provisions for pre-existing conditions. The addition aims to deliver more choice and market competition, which its backers say will lead to lower premiums.
Several moderates are worried this will cause healthy people to flee to less expensive bare-bones plans, making the Obamacare-compliant plans unaffordable.
The revised bill tries to allay those concerns by adding $70 billion to a fund to help states lower premiums. It reinstates some taxes on the wealthy to pay for beefed up spending.
Moderate senators also are very concerned about cuts to Medicaid – $772 billion by 2026, according to the independent Congressional Budget Office score on the Senate’s previous version of the Better Care Reconciliation Act. Medicaid covers more than 70 million people, including the poor, disabled, seniors in nursing homes, and addicts.
To satisfy the Medicaid moderates, the revision provides $45 billion to fight drug addiction in the face of a nationwide opioid epidemic. And if a public health emergency is declared, affected populations can be exempt from caps on federal Medicaid contributions to a state.
“I think right now we’re moving in the right direction but we’ve got room to make additional changes,” said Sen. Mike Rounds (R) of South Dakota, speaking about Medicaid, where there is still disagreement. On Monday, the CBO is expected to report on costs and coverage under the new bill. If senators vote to begin debate on the bill, they will have an opportunity to offer amendments.
Next hurdle: Motion to begin debate
But two Republicans – libertarian Senator Paul and moderate Sen. Susan Collins of Maine – say they will vote “no” on the motion to begin debate on the bill, and another four may not support it either, according to Politico.
It would take only three "no"s to stop the bill in its tracks – preventing it from even getting to the floor for a vote.
Senator Collins said Maine would suffer from the hundreds of billions of dollars of cuts planned for Medicaid. She also strongly objects to the partisan, closed-door process by which the bill has been fashioned, saying that the best way to build solid support for health-care legislation – and for an entitlement reform as big as Medicaid – is through the normal committee process involving Democrats. She has been talking with Democrats behind the scenes.
“I don’t see this as the end if this bill were not to pass," she told reporters, as they clustered around her in a Capitol hallway. "I see it as the beginning of the kind of process that I would have liked to have seen in the first place.”