Senate Unveils Obamacare Replacement

Senate Unveils Obamacare Replacement
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After weeks of private negotiations, Republicans publicly released a draft of their legislation to repeal and replace major tenets of the Affordable Care Act Thursday morning, a week ahead of an expected vote on the measure.

Similar to legislation that passed the House earlier this year, the Senate bill would repeal Obamacare’s individual and employer mandates, as well as most of the new taxes imposed under that law. It would also scale back the ACA’s Medicaid expansion, though on a slower timeline than the House bill prescribes, by beginning to curtail federal funds for the program in 2021 and returning them to pre-Obamacare levels by 2024.

The legislation would also overhaul Medicaid, capping federal spending at a per-person allotment rather than the open-ended funding currently allowed under the program.

Though the broad structure was similar to that of the House measure, there were key differences. The House version provided tax credits based on age to help people afford health insurance; the Senate version would tie those credits to age, income and geography, similar to how they were structured under Obamacare, though they would cover a smaller portion of the population and would cover slightly more generous plans.

It would also not include the state waivers crafted in a key amendment to the House version that helped earn conservative support. The House bill would allow states to seek waivers to opt out of essential health benefits, including maternity care, mental health, prescription drugs and others, as well as a regulation preventing sick people from being charged higher premiums.

Instead, the Senate bill would provide funds to help states seek waivers already in the Affordable Care Act allowing them to make changes to essential health benefits, though they would not be able to waive community rating (the Obamcare regulation preventing insurers from charging higher prices based on health status) under that process.

Republican senators spent more than an hour Thursday morning being briefed privately on the legislation by key staffers of Majority Leader Mitch McConnell’s office and the committees with health-care jurisdiction, though they were not given text of the legislation, which was posted online as they continued their meeting.

Republicans are proceeding using the complex budget reconciliation process, which means they can pass it with just 51 votes while bypassing a filibuster. Before the vote, however, rules dictate up to 20 hours of debate on the Senate floor, split evenly between Republicans and Democrats, followed by an unlimited amendment process, known as a vote-a-rama. Senators in both parties can force votes on as many amendments as they like, which will give Republicans a chance to change the legislation and Democrats a chance to attempt to do likewise or force a number of politically difficult votes. 

Though the vast majority of Senate Republicans appeared likely to support the legislation, several key senators raised concerns within hours of the bill’s release. Rob Portman of Ohio said he had “real concerns about the Medicaid policies in this bill.” Dean Heller, who faces a tough re-election battle next year, said he had “serious concerns about the bill’s impact on Nevadans who depend on Medicaid.” And Susan Collins of Maine told reporters that while there were provisions that improved on the House bill, she also had concerns, including a slower growth rate for Medicaid that would kick in in 2025. She also opposes provisions in the bill defunding Planned Parenthood.

On the conservative side, four senators -- Rand Paul of Kentucky, Mike Lee of Utah, Ted Cruz of Texas and Ron Johnson of Wisconsin -- issued a joint statement in opposition to the measure in its current form, though they said they were open to negotiations. Johnson has suggested a week might not be enough to gauge the impact of the bill. Lee’s top concern has been the repeal of Obamacare regulations, some of which are left in the Senate bill. Cruz said the legislation did not do enough to lower premiums, and proposed myriad fixes that could potentially earn his vote.

Paul’s opposition seemed the staunchest.

“There’s a lot in here that doesn’t look like repeal,” he told reporters not long after the legislation was released. “It looks like we’re keeping Obamacare. So the bill needs to look more like repeal for me to vote for it.”

There is room for negotiation, however. Paul said that while the four conservatives agreed to the initial statement of opposition, he did not say they had agreed to negotiate together, or to keep their opposition in a voting bloc. That gives McConnell and leadership room to maneuver, needing only two of their votes -- if the moderate concerns are also assuaged -- to pass the bill.

Sen. John Thune, the third-ranking Republican in the chamber, admitted that Paul might not be there in the end, but said that he hoped those who were opposed would make clear what they wanted to change, and that most senators were eager to get to yes.

“We’re not voting yet,” he said.

Some Republican lawmakers had complained in recent weeks that they were being kept in the dark about key details of the legislation, though most have said the coming week will provide enough time to review the text. The Congressional Budget Office is expected to release an analysis of the bill early next week. The CBO analysis of the House version estimated that as many as 24 million fewer people would have insurance under the plan, though the assessment of the Senate version is likely to differ based on significant changes.

McConnell will face a difficult whipping process to get the 50 votes necessary to pass the legislation -- Vice President Mike Pence would provide the tie-breaking vote. Some conservatives have expressed concerns that the outlines of the plan presented in recent weeks would not repeal enough of Obamacare or do enough to lower premiums -- though those were based on discussions, not actual text. Some moderates have concerns about the rollback of the Medicaid expansion and potential loss of coverage under the legislation.

McConnell, in a speech on the Senate floor shortly after the legislation was unveiled, said there would be ample time to review the measure before a vote, and said Democrats would have a chance to “do what’s right for the American people.”

“They can choose to keep standing by as their failing law continues to collapse and hurt more Americans, but I hope they will join with us instead to bring relief to the families who have struggled under Obamacare for far too long,” McConnell said.

Minority Leader Chuck Schumer led a group of Democrats on the floor to raise procedural objections to the Republicans’ legislation and to criticize their expedited process for pushing it through the chamber.

Schumer called the bill “every bit as bad” as the House counterpart. “The Senate Republican health-care bill is a wolf in sheep’s clothing. Only this wolf has sharper teeth than the House bill,” he said on the Senate floor.

James Arkin is a congressional reporter for RealClearPolitics. He can be reached at Follow him on Twitter @JamesArkin.

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