Hoping to secure the 50 votes needed for passage, Senate Republicans unveiled their revised draft health care legislation on Thursday that includes some meaningful changes but retains many of the same elements that kept the original version from winning the support of GOP moderates.
With two Republican senators, Susan Collins of Maine and Rand Paul of Kentucky, already opposed to the new bill, Senate Majority Leader Mitch McConnell can afford no further defections if he hopes to pass the bill in a floor vote next week. A disappointing score by the Congressional Budget Office next week, however, could cause McConnell to lose that razor-thin margin.
The revised Better Care Reconciliation Act would scrap the proposed elimination of several taxes on the wealthy that help fund coverage expansion under the Affordable Care Act, also known as Obamacare. Instead it would keep the 3.8 percent tax on investment income, 0.9 percent Medicare tax on high-income individuals and a tax on health insurance executive compensation.
The revenue is expected to help fund a $70 billion increase to the bill's "stabilization fund," now a 10-year, $182 billion pool of money to help states lower premium costs.
Critics say the stabilization fund, which amounts to about 15 percent of the bill's federal health spending reductions, would do little to restore those cuts.
Rather they claim, the fund would give Health and Human Services Secretary Tom Price a massive, unprecedented amount of money to dole out to states as he chooses with almost no oversight or guidance from Congress. The legislation does, however, stipulate that 1 percent of the fund must go to a state with "premiums at least 75 percent higher than the national average."
That state is Alaska, home to Republican Sen. Lisa Murkowski, who has opposed the legislation. It's unclear whether the legislative sweetener will help garner Murkowski's support.
Even with the changes, the legislation still would slash funding for Medicaid, the national insurance program for the poor and disabled, by phasing out the ACA's Medicaid expansion and imposing spending limits that move the program from an open-ended entitlement to one with capped benefits.
In addition, the legislation would allow insurers to charge older people five times more than younger ones, defund Planned Parenthood and impose premium and deductible increases for low-income and poor people and those with pre-existing conditions. It also would cut health insurance to pay for $400 billion in tax cuts that mainly benefit wealthy individuals and corporations, while providing little assistance to the poor.
Andy Slavitt, former acting administrator for the federal Centers for Medicare & Medicaid Services under President Barack Obama, said the bill is "so fundamentally flawed that there is no amendment that could fix everything that is wrong with it."
Democrats and health care advocates also denounced the proposal.
"Trumpcare has been a disaster since day one, and the latest version released today by Senate Republicans is no different," said a statement from House Democratic Caucus Chairman Joe Crowley of New York.
For moderate Republicans uneasy about the original bill's $772 billion cut in Medicaid funding, the revised version doesn't appear to provide much improvement either.
The bill would, however, change the funding formula for federal aid to hospitals that care for a disproportionate share of low-income people. That change will steer more money to states that didn't expand Medicaid by basing funding on the number of uninsured rather than on a state's Medicaid population.
But that wasn't enough to gain the support of Collins. "Still deep cuts to Medicaid in Senate bill," she tweeted, adding that she would vote no on an initial vote to allow formal consideration of the bill.
Collins was pleased the bill can be changed through amendments beginning next week, but said, "I have no idea what the results will be."
Collins and Paul are the only two Republicans who have said they still oppose the legislation.
Sens. Shelley Moore Capito of West Virginia and Rob Portman of Ohio remain undecided even though they got their wish for an additional $45 billion to fund treatment for opioid abuse. Experts say that money wouldn't be enough to take care of the needs now met by Obamacare-related spending.
Many conservatives who have been reluctant to support the legislation cheered the draft, even though it stops short of full repeal of Obamacare, which has been a consistent Republican campaign promise.
They also were heartened that the bill includes a change that would allow Obamacare insurers to sell cheaper, less-comprehensive insurance that doesn't meet Affordable Care Act coverage requirements.
The proposal by Sens. Ted Cruz, R-Texas, and Mike Lee, R-Utah, has been praised by conservatives for giving consumers more choices.
But major health insurers said the provision would destabilize the individual insurance market by causing healthy, younger people to flock to the cheaper coverage, which would drive up premiums for sicker and older people with more comprehensive coverage. That could lead to a "death spiral" in which insurers stop offering coverage as premiums skyrocket and plan enrollment declines.
In a statement, Chris Hansen, president of the American Cancer Society Cancer Action Network, blasted the new option.
"Allowing insurance companies to sell bare-bones, tax-credit-eligible, catastrophic plans would create a segmented insurance market and essentially return cancer patients, survivors and anyone with a serious illness to an underfunded high-risk pool where a patient's out-of-pocket costs could be unaffordable and coverage potentially inadequate," Hansen said.
Republicans have 52 members in the Senate and could lose only two in order to pass the bill under budget reconciliation rules that block Democrats from filibustering tax and health care legislation. In the event of a 50-50 vote, Vice President Mike Pence would cast the tiebreaker.
The nonpartisan Congressional Budget Office will assess the impact and cost of the revised legislation next week, though its assessment of the Cruz-Lee change could take longer.
The CBO's findings will help determine whether Republican support for or opposition to the measure solidifies in the coming days. Senate Majority Leader Mitch McConnell, R-Ky., must decide whether he has the votes to take up the bill and put it to a floor vote next week.
Sen. John Thune, R-S.D., said Senate leadership hopes for a CBO review of most of the legislation by Monday, with an initial vote as soon as Tuesday.
"We know what the issues are, they're just hard decisions," he said of senators like Collins who are worried about the effect of Medicaid cuts on their states. "But at some point we have to move forward."
He said he expected the additional stability funding to alleviate some moderates' concerns, as well as "knowing that states are going to have a lot of flexibility in designing their own programs."
Meanwhile, Sens. Lindsey Graham of South Carolina and Bill Cassidy of Louisiana offered their own proposal that would keep the Affordable Care Act's taxes but send its subsidies to states as block grants rather than to individuals.
Their proposal would repeal the employer and individual mandates to have health insurance, but retain the Obamacare requirement to cover pre-existing conditions. Graham said his idea would give states the flexibility to design their own systems and use the money as they see fit.
Pressure on McConnell is mounting as President Donald Trump, engulfed in deepening Russian election meddling investigations dealing with his campaign and associates, pushes for a legislative victory on his No. 1 campaign promise: to repeal the Affordable Care Act.
Trump said he'd be "very angry" if the Senate fails to pass the legislation.
He told Christian broadcaster Pat Robertson in an interview that McConnell's "got to pull it off." He noted that congressional Republicans have long been talking about repealing Obamacare and voted for ending the law more than 60 times.
"They have to get together and get it done," Trump said, adding that if the Senate fails "it would be very bad. I will be very angry about it, and a lot of people will be very upset."
McConnell has pushed back the August recess, which had been scheduled to begin July 29, by two weeks in order to pass the health care bill. If he can't rally support for the measure, it's possible he could call for a repeal-only vote, which would put vulnerable Republicans in peril for the upcoming 2018 elections.
(c)2017 McClatchy Washington Bureau