The Republican bid to overhaul the health-care industry took one small step forward Wednesday and then essentially went two steps backward.
For a week, some congressional insiders had been whispering that the critical “score” from the Congressional Budget Office, on the legislation that narrowly passed the House earlier this month, might not provide any real deficit savings. Such a finding would have violated the Senate’s more arcane rules for considering budgetary items under fast-track rules — and it might have forced House Speaker Paul D. Ryan (R-Wis.) to redraw the legislation and hold another vote.
So there were a few sighs of relief late Wednesday afternoon when the CBO declared the legislation would find $119 billion in savings over 10 years, more than enough to allow it to pass muster under the Senate’s “reconciliation” rules, which allow a simple majority for passage rather than the usual 60-vote majority. That’s an important feat for Senate Republicans, who control just 52 seats.
But that’s also where the good news ended and reality set in about the rest of the legislation. The congressional analysts — led by a Republican hand-picked by Ryan — found that 23 million more people would be left uninsured than under the current law, the Affordable Care Act.
The $119 billion in savings would result mostly because fewer people would be covered under the ACA’s expansion of Medicaid — and because the new legislation would loosen requirements on the quality of coverage that insurers would have to provide.
For a core group of Senate Republicans, those facts may be all they need to bury the House version of a health-care overhaul once and for all. They also highlight just how high the hurdle is to get a health-care bill to President Trump’s desk.
These senators already had built up staunch opposition to Ryan’s House-passed bill, when CBO estimates back in March suggested that the initial draft would leave 24 million more uninsured than under the ACA. After Wednesday’s updated estimates, those Senate Republicans, predominantly from states with large populations of people who benefited from Medicaid expansion, dug in even further against the House bill because millions of their constituents would be left in the lurch by the GOP proposal.
“That’s tough to swallow,” said Sen. Shelley Moore Capito (R-W.Va.), who has 180,000 constituents relying on the Medicaid expansion for insurance coverage.
Capito, part of a bloc of 20 Republicans from Medicaid-expansion states, has been a vocal opponent of the House bill for so quickly transitioning away from that ACA benefit. She says this updated estimate puts steel in the spines of those Republicans, including Sens. Rob Portman (Ohio), John McCain (Ariz.) and Lisa Murkowski (Alaska).
“It strengthens my resolve,” Capito said. “To say, what are we doing to people here, particularly to our most vulnerable or those that don’t have the wherewithal?”
Said McCain: “Yeah, I think it helps. I think it helps the Medicaid states.”
With every Democrat opposed to the effort and just 52 Republicans in the Senate, Majority Leader Mitch McConnell (R-Ky.) knows that the Capito-McCain wing is the most critical to getting close to the 50 votes he needs from his side of the aisle — which would allow Vice President Pence to cast the tiebreaking vote.
But each move to appease these Republicans risks losing a few more votes on the conservative end of McConnell's caucus, including his home-state colleague, Sen. Rand Paul (R-Ky.), who seems dead set against supporting anything that is not seen as a complete gutting of the bill Republicans derisively call Obamacare.
Sens. Ted Cruz (R-Tex.) and Mike Lee (R-Utah) have been more aligned with the House Freedom Caucus, which negotiated key portions of the legislation.
The jigsaw puzzle has left McConnell expressing rare bouts of public pessimism about such a big piece of legislation, something he campaigned on himself in his 2014 reelection effort — repealing and replacing Obamacare.
In a Wednesday interview with Reuters, the Republican leader began by telling his interviewers not to bother with questions about the ongoing health-care negotiations. “There’s not a whole lot of news to be made on health care,” McConnell said, adding later that he was struggling to find a path to getting those 50 votes. “I don’t know how we get to 50 at the moment. But that’s the goal.”
Even if he can finesse the divide between his rock-ribbed conservatives and his Republicans from Medicaid-expansion states, McConnell risks blowing up what had been a meticulously crafted coalition in the House, where Ryan won, after weeks of fits and starts, by a two-vote margin.
Sen. Bill Cassidy (R-La.), a physician who has been trying to find common ground, said that the CBO report would probably provide some good news that Senate negotiators could seize on. “Those conservative families that voted for Trump need relief from $20,000-a-year premiums,” Cassidy said, giving Senate negotiators the chance to exhume parts of the mostly dead-on-arrival bill from the House.
“You want to look at different components of it,” Cassidy said. “It may be that some of it you keep and some of it you discard.”
However, the CBO was clinical in its explanation for the lower premiums — “because the insurance, on average, would pay for a smaller proportion of health care costs.”
That means worse coverage, and many Senate Republicans are wary of passing a law that will stick their working-class voters — many of whom come from regions that voted overwhelmingly for Trump — with deteriorated coverage.
Now Republicans are left to their working groups in the Senate, trying to find the right mix. Veteran Republicans including McCain know that what they need to do is put together a draft piece of legislation where almost all of it is agreed upon, then start getting into the final wheeling and dealing on the last critical details.
“Right now there’s a lack of cohesion. Now, once they get a base bill, then I think you’re going to see a lot of back and forth,” McCain said. “But so far they haven’t come up with a piece of legislation to work with.”