On a squeaker of a vote, the Senate began an extraordinary debate Tuesday over profound philosophical and practical changes to the nation’s health-care system — without knowing what the legislation would be.
Lawmakers started with a bill that the House passed this spring to dismantle much of the Affordable Care Act. It is a measure that many Senate Republicans have never liked and was brought up Tuesday solely to kick things off.
The action then immediately pivoted to another bill that also had no realistic chance of success: a reprise of a plan to kill off big parts of the ACA without any replacements. It was adopted two years ago by both chambers of Congress and was vetoed by President Barack Obama.
By nighttime, the Senate had taken its first vote, rejecting one permutation of its main anti-ACA legislation and moving on to another amendment. The measure that failed, with nine Republican senators opposed, was one that included amendments by Sens. Ted Cruz (R-Tex.) and Rob Portman (R-Ohio.)
And so began a legislative kaleidoscope scheduled to last for 20 hours of debate in coming days, followed by yet more amendments and votes. Even as it started turning, a new last resort already was in sight — a skimpy plan being dubbed “skinny repeal” that could stand mainly as a way to keep the health-care issue alive at least through the summer.
After seven years of GOP promises to tear down the ACA, this is the unpredictable course on which Senate Majority Leader Mitch McConnell (R-Ky.) now finds himself. Despite his reputation as a master tactician, McConnell has been unable in recent weeks to wrangle his fractious caucus into a cohesive health-care voting bloc.
Based on what senators were saying on Tuesday, here are some of the plans and amendment likely to come up for debate or a vote — potentially in different combinations — in coming days.
This is the main legislation that the Senate’s Republican leaders have devised to get rid of much of the ACA and substitute a more conservative set of health policies. Originally introduced June 26, it is now in its third version and is almost certain to be altered further.
The Better Care Reconciliation Act (BCRA) would eliminate central features of the current law, which a Democratic Congress pushed through in 2010. It would end federal penalties for people who violate the current law’s requirement that most Americans carry health insurance and for employers with 50 or more workers who do not offer health benefits. It also would cut the subsidies that help more than 8 in 10 consumers afford the monthly premiums of health plans they buy through the ACA’s insurance marketplaces.
The plan would substitute a different form of tax credits, smaller for many people because they would be tied to skimpier health plans. Unlike the ACA subsidies, however, the proposed credits would be available to people below the federal poverty line.
After two years, the bill also would abolish a different ACA subsidy that now helps about 7 million lower-income consumers afford their coverage deductibles and other out-of-pocket expenses.
Medicaid, the joint state-federal program of health insurance for the poor, would be transformed in two ways. The expansion of the program undertaken by 31 states under the ACA would be phased out in a few years. More fundamentally, its half-century tradition as an entitlement — with the government paying a certain share of the costs in each state, no matter how high — would be replaced by per-person caps or block-grant funding. Either is predicted to squeeze the federal payments as time goes on.
Late last week, the Senate’s parliamentarian threw a wrinkle into Senate Republican leaders’ plans, concluding that certain aspects of the legislation could not be considered through a budget process that would allow it to pass by a simple majority of votes. These include features, popular among conservatives, that would deny funding for Planned Parenthood and health plans that allow coverage for abortions. Senate aides say the provisions are likely to be rewritten to meet the parliamentary rules. It is not yet clear how.
Sen. Ted Cruz (R-Tex.) has been touting a change to the Better Care Reconciliation Act that would enable insurers largely to ignore ACA rules requiring health plans sold to individuals and small businesses to cover specific benefits. Insurers could jettison maternity care, mental-health treatment and other benefits as long as they sell as least one health plan that includes them.
Cruz has said that this change would lead to lower insurance rates for healthy people, and analysts suggest that it would do so. However, analysts also expect that people who need more medical care would face significantly higher prices, because health plans’ “risk pools” would be splintered between healthier and sicker groups.
This amendment has been unpopular with GOP centrists in the Senate.
Sen. Rob Portman (R-Ohio) comes from a state that expanded Medicaid and has been outspoken in predicting that the BCRA eventually would starve the program and leave more people uninsured.
He now has come up with a variation of an idea that the Trump administration’s top health officials have been heavily lobbying expansion states to embrace: tax credits that people on Medicaid would receive to buy private health plans. Many of the governors targeted have said no to the administration’s offer, predicting that such low-income residents still could not afford the private coverage.
Portman’s amendment would provide $100 billion to help those people cover their deductibles and other expenses if they switched out of Medicaid, and it would let states set up such arrangements without needing special federal approval.
The only repeal bill ever to pass Congress would have left intact some popular ACA insurance rules, such as letting young adults stay on their parents’ health plans to age 26. But the 2015 measure would have ended the law’s coverage mandates, its subsidies for most people buying health plans through the ACA marketplaces and the law’s Medicaid expansion.
Sen. Rand Paul (R-Ky.) has championed this kind of repeal without substitutes, viewing it as a purer version of ACA repeal and thus more acceptable. He provided a crucial vote to start the health-care debate Tuesday after being promised that the chamber would vote on this measure. Other Republicans, however, abandoned the idea of a repeal-only bill months ago, believing it would upend coverage for millions of people and devastate insurance markets.
Adding a new phrase to the crowded lexicon of health-care policy, “skinny repeal” would abolish just three parts of the ACA: the individual and employer insurance requirements, plus a tax on medical-device manufacturers.
A close variant of this surfaced two years ago in the House, and congressional budget analysts estimated at the time that 15 million fewer Americans would have insurance coverage “most years” as a result.
The idea is now as much tactics as policy. A slimmed-down repeal plan probably would surface on the Senate floor as an amendment if the chamber is unable to pass a fuller demolition of the law. It would buy the Senate’s GOP leaders more time, because its passage would lead to a conference committee with the House.
Negotiations between lawmakers of the two chambers could then continue past Congress’s August recess, preserving the ability of McConnell and other GOP leaders to keep searching for a health-policy formulation that could garner the support of enough members of their caucus.