Senate Republicans have finally revealed their plan to revamp the Affordable Care Act. Now, they're just trying to pass it. There will be lots of twists and turns along the path to an anticipated vote next week -- and it's by no means assured the GOP will get there.
Capitol Hill was awash yesterday with reaction to the health-care bill released by Senate Majority Leader Mitch McConnell (R-Ky.), which would retain some key components of the ACA while still erasing its taxes and Medicaid expansion. The bill isn't dead on arrival -- no GOP senators have permanently closed the door on voting for it -- as long as some concessions are made. But if McConnell succeeds in uniting his deeply skeptical conference around the measure, he could legitimately be labeled a legislative wizard.
McConnell can afford to lose just two Republican senators in his 52-vote caucus because the GOP bill has to meet a threshold of a 50-vote simple majority given the fact it is being subjected to arcane budget rules (and that would leave Vice President Pence to cast a tie-breaking vote for approval).
It is a very tall order. By The Post's whip count, a dozen Senate Republicans have indicated they oppose or have concerns about McConnell's "discussion draft." Moderates were circumspect on Thursday, saying they still have concerns about the bill and need to spend more time reviewing it. On the other end of the spectrum, four conservatives -- Sens. Ted Cruz of Texas, Mike Lee of Utah, Ron Johnson of Wisconsin and Rand Paul of Kentucky -- said outright they'd cast their votes against the bill without further rollbacks to Obamacare.
See more about the four Republicans who say they're not ready to vote for the Senate's health-care bill:
How things play out over the next week will be pivotal to Republicans' seven-years-long quest to repeal and replace President Obama's signature domestic achievement. If enough senators unite to pass McConnell's bill, Republicans will have come a long way toward achieving their goal. Despite the fact the House would have to sign on (no easy feat, mind you), a stamp of approval from the upper chamber means President Trump is more likely to be able to enact a major priority. If the McConnell falls short, that loss could spell doom for the whole effort and mean that the GOP -- with one-party control of Washington -- reneges on one of the biggest political promises in recent memory.
Trump threw his weight behind the Senate measure last night:
I am very supportive of the Senate #HealthcareBill. Look forward to making it really special! Remember, ObamaCare is dead.— Donald J. Trump (@realDonaldTrump) June 22, 2017
My colleague Amber Phillips lays out several scenarios that could doom the bill. Anti-Obamacare purists could draw a line. Midwest Republicans just can't agree to cut Medicaid so deeply. At least three senators with state-specific issues hold out. If any one of these scenarios transpires, the bill is dead. On that note, here's a list of the senators we're watching most closely and what they said yesterday about the health-care measure:
--Sen. Susan Collins of Maine: "I see some positive features in this bill that are improvements over the House, and I see some negative features, based on my first analysis," she told my colleague Dave Weigel. Collins said she likes how the bill would make insurance subsidies available to earners under $12,000. But she is "very concerned" about the long-term cuts to Medicaid spending.
The Boston Globe's James Pindell tweeted Collins's statement:
Senator Susan Collins (R) is undecided on health care bill. Waiting for CBO score next week. pic.twitter.com/BQC9PR1icu— James Pindell (@JamesPindell) June 22, 2017
--Sen. Dean Heller of Nevada, who McConnell will be worried about placating as he is one of two GOP incumbents at serious risk of losing their seats in the 2018 midterms: "I have serious concerns about the bill’s impact on the Nevadans who depend on Medicaid," he said in a statement.
CNN's Phil Mattingly tweeted the full statement:
Sen. Heller on Sebate GOP health care draft: "At first glance, I have serious concerns..." pic.twitter.com/l5TvIOfsMu— Phil Mattingly (@Phil_Mattingly) June 22, 2017
Heller said he supports the Senate bill's gradual, seven-year phase-out of Medicaid expansion, but would have preferred a 10 or 15-year phase-out, according to Jon Ralston, editor of The Nevada Independent. “If they asked me two or 10 years, I’d have said 10. If they asked me two or 15, I probably would have said 15,” Heller said.
--Sen. Lisa Murkowski of Alaska: Murkowski reiterated yesterday that she does not support defunding Planned Parenthood and wants that language removed from the bill. But both Murkowski and Collins -- the only two Senate Republicans who support abortion rights -- stopped short of saying its inclusion would prevent them from ultimately voting for the measure, Bloomberg's Sahil Kapur noted:
Just asked Murkowski about defunding @PPFA.— Sahil Kapur (@sahilkapur) June 22, 2017
"I support Planned Parenthood."
The bill defunds it for a year.
"I do not support defunding."
Susan Collins stops short of calling Planned Parenthood defunding language a dealbreaker for her, saying she and Murkowski want it removed.— Sahil Kapur (@sahilkapur) June 22, 2017
--Sen. Rob Portman of Ohio: Portman was vague and noncommittal either way. He said in a statement that there are "promising changes to reduce premiums" in the Senate bill but "I continue to have real concerns about the Medicaid policies in this bill, especially those that impact drug treatment at a time when Ohio is facing an opioid epidemic." The Senate bill contains some funding for opioid abuse, but much less than Portman had asked for.
--Sen. Shelley Moore Capito of West Virginia: Capito said she "will review the draft legislation released this morning, using several factors to evaluate whether it provides access to affordable health care for West Virginians." She said she wants to know how it would affect people on Medicaid expansion and those struggling with drug addiction.
My statement on the Senate health care discussion draft: https://t.co/hlC90OCrSo— Shelley Moore Capito (@SenCapito) June 22, 2017
The Washington Examiner's Robert King noted that Capito didn't explicitly warn she has concerns, as some of the other senators did:
Capito gives cautious statement on health bill, says she will review it but doesn't say she has concerns like Heller and Collins.— Robert King (@rking_19) June 22, 2017
--Sen. Rand Paul of Kentucky: Paul's leading the foursome of Republicans who are opposing the bill in its current form. He tweeted his joint statement with Sens. Cruz, Lee, Johnson and Toomey. "We are not ready to vote for this bill, but we are open to negotiation and obtaining more information before it is brought to the floor," the statement says.
Paul told reporters that the bill "looks like we're keeping Obamacare, not repealing it," in a video MSNBC's Kyle Griffin tweeted:
--Sen. Ted Cruz of Texas: Cruz gave perhaps the most detailed reaction. He said he's pleased that the bill would expand association health plans, tamp down Medicaid growth long-term and prohibit federally subsidized plans from covering abortions. But the draft "does not do nearly enough to lower premiums," he said.
"That should be the central issue for Republicans – repealing Obamacare and making healthcare more affordable," Cruz said in a statement. "Because of this, I cannot support it as currently drafted, and I do not believe it has the votes to pass the Senate."
CNN's Lauren Fox shared an image of a note Cruz passed around with his "Path to Yes":
Sen. Ted Cruz handed these out today in Senate lunch. How he can get to yes. pic.twitter.com/WYeQYxbcLe— Lauren Fox (@FoxReports) June 22, 2017
--Sen. Mike Lee of Utah: Lee echoed Cruz's criticism that the bill wouldn't go far enough toward bringing down premiums and repealing Obamacare:
--Sen. Ron Johnson of Wisconsin: "I am not a 'yes'," Johnson told reporters, per a tweet from CNN's Teddy Davis:
GOP Sen. Ron Johnson speaking to reporters outside Capitol: "I am not a 'yes.'" Says GOP /Dems should start over on bipartisan health bill.— Teddy Davis (@TeddyDavisCNN) June 22, 2017
--Sen. Pat Toomey of Pennsylvania: Toomey said he’s “likely” to vote for the bill in a call with reporters Thursday afternoon. He said it needs ongoing work, but that he could still support it in its current form. “I don’t have a list of things at this point I must change,” Toomey said. “Everything I want is not going to happen in one bill.
Today, the Senate unveiled a draft bill aimed at fixing America's failing health care system. Read my statement: pic.twitter.com/JNbJKNP3eV— Senator Pat Toomey (@SenToomey) June 22, 2017
Toomey was a big proponent all along of the deeper cuts to federal Medicaid spending starting in 2025. He's really happy that part was included, The Hill's Peter Sullivan noted:
Toomey says lower Medicaid growth rate in 2025 will put program on "sustainable path."— Peter Sullivan (@PeterSullivan4) June 22, 2017
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AHH: The Senate’s third-ranking Republican acknowledged the narrow path to 50 votes, especially now that the Paul/Cruz/Lee/Johnson group has defected for the time being, leaving potentially just 48 votes for the measure.
“Forty-eight — that’s not enough to pass,” Sen. John Thune (R-S.D.) told supporters. But he sought to reassure them. “We’re not voting yet," he added.
OOF: Former President Obama jumped in quickly yesterday, charging in a lengthy Facebook message that the 142-page draft measure is "not a health care bill."
“It’s a massive transfer of wealth from middle class and poor families to the richest people in America,” Obama wrote on Facebook. “It hands enormous tax cuts to the rich and to the drug and insurance industries, paid for by cutting health care for everybody else.”
Obama didn't mention Trump in his post. But he appeared to take a swipe at his successor and his reported characterization of the House bill as “mean." “Small tweaks over the course of the next couple weeks, under the guise of making these bills easier to stomach, cannot change the fundamental meanness at the core of this legislation," Obama wrote.
The Post’s David Nakamura noted that Obama had pledged to lay low after leaving the White House. But he made an exception with the law nicknamed after him:
“It is on health care that Obama has perhaps the most to lose and, with his lengthy Facebook statement, has signaled his intention to have the most political influence. Though he opened his message with an attempt to elevate the debate — emphasizing the need to listen to those with opposing points of view — he quickly framed Republican motivations as purely partisan,” Dave writes.
OUCH: Humana says it will not return to the individual insurance market no matter what happens to Obamacare, Reuters reports. It's among the major insurers that have pulled back from specific states or fled the marketplace altogether citing heavy losses and uncertainty. The company had announced back in February that it would leave the marketplaces entirely, and its CEO said yesterday that decision isn't contingent on Republican action to revamp the Affordable Care Act.
“This is just not a business that we will be good at,” Humana CEO Bruce Broussard said in an interview. “No matter what they do in Washington, we are not going to go back in. And we’ve had a lot of people ask us from Washington D.C. if we would go back in and we’ve said no, it’s not there.”
Other insurers also declared exits this week, as the federal rate filing deadline came and went. Anthem announced Wednesday it was leaving the Wisconsin and Indiana marketplaces, after earlier this month saying it would pull out of Ohio. The withdrawals have put some counties in serious jeopardy of having no marketplace insurer next year. Here is a map from the Kaiser Family Foundation showing counties where people are at risk for having no options for insurance in 2018.
--Trump told Fox News that he thinks Senate Republicans will manage to pass their measure. “I think that they’ll probably get there,” Trump said in the interview, previewed by CBS News. Trump added that the four holdout senators (Paul/Cruz/Lee/Johnson) are “friends of mine." “But we’ll have to wait and see," he said.
And last night, the president hopefully retweeted Fox Nation saying Cruz "wants to get to 'yes.'"
The night before the bill was released, at a campaign-style rally in Cedar Rapids, Iowa, Trump told his supports he wanted to “add some money” to the health-care bill so it can have more “heart.”
And on Thursday, as Senate Republicans were meeting for the bill's rollout, Trump said the bill will be "something with heart" but will need further changes. “Obamacare is dead, and we’re putting a plan out today that is going to be negotiated,” he said. “We’d love to have some Democrats’ support, but they’re obstructionist.”
--Pence expressed confidence that the bill would land on Trump’s desk “before summer is out.”
“Today, my fellow Americans here can be assured before the summer is out — working with the Congress — President Donald Trump will keep his promise to repeal and replace the Affordable Care Act,” Pence said at the Woodrow Wilson International Center for Scholars. “We look forward to working with the Senate majority to move this legislation forward.”
--Health and Human Services Secretary Tom Price, a former Republican congressman himself, gave the Senate measure a resounding endorsement:
The Senate’s proposal is built on patient-centered reforms that put the American people back in charge of their own healthcare decisions.— Tom Price, M.D. (@SecPriceMD) June 22, 2017
--Protests broke out around Washington on Thursday over the Senate health-care bill, as patient advocates flooded Capitol Hill to register their opposition to its deep Medicaid spending cuts. Dozens of people were arrested after staging a "die-in" outside McConnell's office, the Post's Perry Stein reports.
"The protest, organized by the disability advocacy organization ADAPT, was intended to pressure McConnell and other Republicans not to cut Medicaid funding," Perry writes. "The protesters staged a “die-in” in front of the office, with many of the protesters in wheelchairs removing themselves from the chairs then lying on the floor … U.S. Capitol Police spokeswoman Eva Malecki said officers warned the demonstrators to 'cease their unlawful activities' or risk being arrested. Those who did not comply were arrested and charged with crowding and obstructing."
Here's a video of protesters being led away after blocking McConnell's office:
Some protesters followed senators to Reagan National Airport as they departed on flights back to their home states. Igor Volsky, with the liberal Center for American Progress, captured some of it on video:
Impressive turnout here as at Reagan National Airport protesting the Senate health care repeal bill https://t.co/WNioSbi2g1— igorvolsky (@igorvolsky) June 22, 2017
--Jonathan Gruber, the health economist famously known as an "architect" of Obamacare and a big supporter of the law, had an interesting twist on the bill. Gruber noted to CNN that the GOP measure actually retains some big parts of the ACA (like its insurance subsidies). From the Daily Beast's Lachlan Markay:
ACA architect Jonathan Gruber on the AHCA: "This is no longer an Obamacare repeal bill. That's good." https://t.co/vdwP2Ad3Sj— Lachlan Markay (@lachlan) June 22, 2017
--Some Democrats posted photos of themselves reading the draft bill, underscoring how they weren't invited to weigh in through the process as it was being written:
Some Republicans did, too:
Sen. Ben Sasse (R-Neb.):
Drew presiding duty this afternoon. Looking forward to a few hours of reading time... pic.twitter.com/41kFjyrCJo— Ben Sasse (@BenSasse) June 22, 2017
A few more interesting reads about the Senate health-care measure:
Let's take a tour through what the public thinks about the provisions in the Senate bill -- and the law it would replace.
--Like the House bill, the Senate version would allow insurers to charge older people more relative to younger people, by a ratio of 5-to-1 instead of the current 3-to-1. This idea is widely unpopular, opposed by 81 percent of respondents in a U-Md./Brookings national study released this week. Notably, 66 percent of Republicans and 80 percent of people in heavily Republican congressional districts opposed the idea.
--Rolling back Medicaid expansion, as the Senate bill would do, is unpopular in general. A May Kaiser Family Foundation poll found a greater percentage saying cuts to the ACA’s Medicaid expansion made them less likely to support the House bill than more likely (43 percent less likely, 23 percent more likely), while about one-third said it made no difference (34 percent).
--The Senate bill would repeal the ACA's individual mandate to buy coverage and employer mandate to offer it. The individual mandate is one of the ACA’s least popular provisions – 63 percent had an unfavorable view of it in a November Kaiser poll. But the employer mandate is better-liked. A November Kaiser Family Foundation poll found 60 percent of Americans have a favorable view of the requirement for employers with 50 or more employees to pay a fine if they don’t offer health insurance.
--Reducing taxes on higher-income households tends to be unpopular, and a May Kaiser poll found similar results regarding ACA taxes (which the Senate bill would repeal). Some 49 percent of Americans said rolling back the law's taxes on higher-income people would make them less likely to support a health-care bill, while 18 percent said it would make them more likely to back it. Among Republicans, 30 percent said eliminating tax increases for higher-income people made them more likely to support the bill.
--The House bill provides waivers allowing insurers to charge some people with preexisting conditions higher premiums, but the Senate bill retains the protections for these patients. Such waivers were widely unpopular in surveys that tested them, suggesting their removal could boost support for the law. In the May Kaiser poll 65 percent said they’d be less likely to support a bill that allowed states to decide if health insurance companies can charge sick people more than healthy people if they lack continuous coverage, compared with 12 percent who said it made them more likely to back it.
--And as Republicans unveiled their highly anticipated draft yesterday, the Wall Street Journal and NBC released a poll showing 41 percent of people approve of the Affordable Care Act compared to 38 percent who do not. Nearly half of respondents — 48 percent — said the House health-care bill, which the Senate draft mimics in many ways, was a bad idea.
--Health insurers had little to say about the Senate bill yesterday. "We continue to analyze the bill, consistent with our previous positions," Kristine Grow, spokeswoman for America's Health Insurance Plans, told The Health 202.
But provider groups had mixed or largely negative reviews. The American Medical Association said it is still reviewing the bill but has "grave concerns" with its cuts to Medicaid spending. The American Academy of Pediatrics said it "fails to meet children's needs." The American Academy Of Family Physicians said reflects many of the same "flawed concepts" as in the House bill and in many ways, poses "a graver threat to millions of Americans, particularly children, people with disabilities and older Americans." The American Hospital Association said the Senate should "go back to the drawing board."
--Democrats have been slamming Republicans for crafting their health-care bill behind closed doors. But were they a model of transparency while writing the Affordable Care Act? Not exactly, Post Fact Checker Glenn Kessler reports.
To highlight the secrecy of the GOP health-care deliberations, many Senate Democrats have pointed out that the debate over the ACA marked the second-longest consecutive session in Senate history. Here's what Senate Minority Leader Charles E. Schumer said on Monday:
Schumer: “Twenty-five days of consecutive session on a bill that was partisan in the sense that Republicans were angry with it, but we still had the courage of our convictions to have a debate on the floor.”
Was Schumer right? Technically, yes. But this statistic obscures a reality: The key work on creating the Senate version of the ACA was done in secret, Glenn writes. (The Health 202 has written about this before as well)
The reality: "The biggest difference between the Democratic effort to reshape health care in 2009-2010 and the Republican effort to undermine that achievement is that the Democrats made full use of the committee process," Glenn writes. "Republicans have skipped the days of hearings and lengthy markups that were a feature of the crafting of Obamacare."
But while Senate Democrats wrote different health bills in two committees, those bills were merged by then-Senate Majority Leader Harry M. Reid (D-Nev.) secretly in his office -- much like McConnell's approach now. The real work after that went on behind closed doors, in Reid's office, where he negotiated significant changes with a group of moderate Democrats. During those private talks, Reid agreed to remove a public option in the bill, as well as drop a plan to allow people between the ages of 55 and 65 to buy into Medicare, among other changes.
The takeaway: "Republicans have skipped the lengthy, open process of hearings and markups of legislation that characterized the Democrats’ march to passage of the ACA," Glenn writes. "Instead, they moved directly to floor votes. Moreover, Democrats at first tried to enlist some Republican support, while Republicans have not reached out to Democrats."
"But recalling the second-longest Senate session obscures the fact that the floor debate was mostly for show, an exercise designed to allow the closed-door negotiations that shaped the final bill to take place," he continues. "Once the deal was struck, Reid pushed the final draft forward with as much speed as possible. That’s what McConnell is doing now, having skipped the preliminaries."
- The House Energy and Commerce Subcommittee on Health will hold a hearing on safety net health programs.
- The American Enterprise Institute is holding a discussion on the government’s role in medical innovation and funding on June 29.
Four ways the Senate health-care bill could fall apart:
Trump says the GOP health-care bill will have ‘heart’:
Trump’s claim about the ‘catastrophe’ of Obamacare premiums increasing 204 percent in Alaska:
House Speaker Paul D. Ryan (R-Wisc.) comments on health care:
Sen. Debbie Stabenow (D-Mich.) says the health-care bill will "rip health care away from millions of Americans":
Schumer says the Senate health-care bill "is a step to eradicating" Medicaid:
Seth Meyers says Senate Republicans are trying to rush their “Cruel Trumpcare Bill”:
Jimmy Kimmel talks to kids about health care: