Senate Republican leaders on Tuesday unveiled a series of policy options to overhaul the nation’s health-care laws, but substantial disagreements remained even as leaders aimed to conclude their perilous and divisive effort as soon as later this month.
During a closed-door luncheon for all Republican senators, Majority Leader Mitch McConnell (Ky.) delivered a slide presentation offering choices on how to structure Medicaid, tax credits to help people pay for insurance, and ways to stabilize the insurance marketplace and bring down the cost of premiums, according to Republicans familiar with the closely-guarded session.
Some of the proposals in the presentation, which was the most specific health-care discussion yet among the 52-member Senate GOP Conference, would amount to a less aggressive assault on the Affordable Care Act, known as Obamacare, than a bill that passed the House last month.
For example, McConnell favored dropping a House provision that would end guaranteed protections for people with preexisting medical conditions, according to three Republicans familiar with the meeting. The House bill would allow states to seek waivers to opt out of a regulation requiring that such people may not be charged more for coverage. McConnell proposed the possibility of keeping waivers that pertain to other key regulations.
But it was unclear whether a lighter touch would satisfy the many Republican senators worried about shredding too much of the law — and whether a handful of influential conservatives would revolt.
“You know, the big print giveth, the small print taketh away. I’m looking for the small print at this point,” said a cautious Sen. Dean Heller (R-Nev.) as he exited the lunch. Heller is up for reelection in a purple state that expanded Medicaid under the ACA.
Republicans are trying to make major strides on health care on the eve of former FBI director James B. Comey’s public testimony on Thursday before the Senate Intelligence Committee. Coupled with talks that have not yet sparked sufficient support for a health-care bill, the looming Comey drama has prompted several lawmakers to wonder if their plans to move forward in the coming weeks could also be thwarted by Trump’s lack of focus on the legislation because of the controversy swirling around the FBI and congressional investigations into potential coordination between the Trump campaign and Russia.
Sen. Ted Cruz (R-Tex.), a hard-line conservative from a ruby red state, was optimistic about the progress Tuesday but stopped short of endorsing any of the options presented in the meeting. “Failure is not an option,” he warned afterward.
Sen. Lindsey O. Graham (R-S.C.) predicted before Tuesday’s lunch that Sen. Rand Paul (R-Ky.) would vote against the bill and leave Republicans with only one more “no” vote to spare. Paul spokesman Sergio Gor responded afterward that Graham should not be speaking for his boss, who “remains optimistic the bill can be improved.”
McConnell’s presentation was described by attendees as a walk-through of major goals and options and how to achieve them. Medicaid was one focal point.
Sen. John Barrasso (R-Wyo.) said leaders proposed gradually reducing federal payments to states that accepted Medicaid expansion under the ACA. That would give recipients more time to ease out of the program and into purchasing coverage on their own or through an employer rather than under the House bill.
“We talked about ways to have a smoother glide path, rather than an abrupt cutoff,” said Barrasso. There have been worries among GOP senators from Medicaid expansion states that the House bill’s rollbacks to Medicaid would be too abrupt and severe. This Senate proposal would extend the timeline beyond 2020.
Tax credits are another topic on which leaders are hoping to build consensus. Senate Republican Conference Chairman John Thune (R-S.D.) has been looking at ways to adjust the tax credits in the House bill to offer more assistance to elderly and lower-income Americans.
Separately, the Senate parliamentarian decided Tuesday that the House legislation fits into a Senate budget rule that would allow the health-care bill to pass with a simple majority rather than having to clear a 60-vote threshold needed for most other legislation. That ruling is the first of several complicated procedural steps that must happen before the Senate can vote on a final bill.
Democrats will now have the chance to challenge whether individual elements of the House bill, including waivers to allow insurers to drop protections included in the ACA, like mandatory coverage of prenatal and maternity care, can stay in the Senate bill.
McConnell said after the meeting that Republicans are “close to having a proposal to whip and take to the floor.” His top deputies have signaled this week that they are eyeing a vote by the end of July on a bill to be completed by early that month, with some aspiring to wrap up even sooner. Their comments reflect a growing desire to bring a difficult debate to a close one way or the other.
“Obviously, we’re going to have a vote one way or the other, but if we don’t pass something and we go into ’18, you know, it’s on us to try and get this fixed,” said Thune on Monday. Asked Tuesday whether he would hold a vote without having the 50 votes necessary to pass it, McConnell would not say.
Tuesday’s talks came after weeks of discussion in small and large groups of Republican senators. Some, though, were skeptical Tuesday about the partisan approach leadership opted to take.
As a growing number of senators have publicly doubted a health-care bill can pass, some Senate Republican aides and associates are already privately discussing how the GOP would craft its midterm campaign message if it fails to pass a health-care bill, suggesting they could tell voters they need to build a bigger majority to finally undo the ACA.
“Quietly, people are preparing for a lot of possible outcomes and how to deal with them,” said one Republican in frequent communication with GOP senators and staff, who like other aides and allies interviewed for this story were granted anonymity to speak candidly.
The differing ideas on health-care reflect not only contrasts in policy but sensitivities to opposite ends of the political spectrum, with some concerned about an electoral backlash from centrist or left-leaning voters who oppose major changes to Obamacare and others worried that a less aggressive assault on the ACA will leave right-leaning opponents of the law dispirited.
Some Republicans want to move on so that Congress can focus on pressing deadlines in the late summer and early autumn, including a vote to increase the federal borrowing limit that could come as early as mid-July. Republicans have also suggested that they want to begin negotiations with Democrats on a long-term spending bill before Sept. 30, when the fiscal year ends, and take up tax reform, another sweeping GOP legislative goal.
Much of the serious policy work has been conducted behind the scenes by a small group of health-policy staffers, with members of McConnell’s inner circle leading the political strategy, according to top GOP aides familiar with the negotiations. Experts have been working to craft a number of policy options that lawmakers can mix and match to create a final policy outline.
Complicating matters, leaders must also jump through a series of other procedural hoops, like waiting for an official cost estimate before the health-care bill can come up for a vote. That process typically takes around two weeks, meaning leaders would need to have a final bill in hand soon to get it scored and hold a vote by the end of next month.
Senate budget rules allow GOP leaders to scrap nearly every element of the health legislation that passed the House. The only requirement is that the Senate measure must save $133 billion over the current law, the same amount saved in the House bill.
Vice President Pence, who could break a 50-5o tied vote on health care should he need to, attended Tuesday’s regularly scheduled policy luncheon, as he often does. But even as Pence represented President Trump at the crucial gathering, some Republicans have doubted the president’s focus on the debate — which is another complicating factor on top of the many others.
“Judging from his tweets, I would say that he has partly moved away from the health-care debate,” Sen. Susan Collins (R-Maine) said in an interview. “He seems more focused on terrorism, his dispute with the mayor of London, his recent foreign trip and his infrastructure package.”
Ed O’Keefe, Robert Costa, Paul Kane and David Weigel contributed to this report.