WASHINGTON — The hot dogs have been eaten, the fireworks are gone and the parades are long over. Now the clock is ticking on Senate Republicans’ efforts to pass a replacement for the Affordable Care Act (ACA) as they scramble to vote on a bill as early as next week.
Republican leaders have proclaimed that a revised version of the Better Care Reconciliation Act is in the works as they try to address concerns of their members across the ideological spectrum. Politico reported that a revamped version of the bill could be presented to lawmakers as soon as Thursday, after 10 GOP senators and counting have expressed opposition to the first draft of the bill.
Because of united Democratic opposition, Republicans can lose only two votes and still pass the legislation.
“We’re just trying to get a good picture of what the alternatives are, and hopefully next week we’ll be prepared to take the bill up and vote on it,” Senate Majority Whip John Cornyn, R-Texas, told reporters Monday.
Republican critiques have included the law’s sharp cuts to Medicaid, insufficient funding to combat the opioid crisis, and not going far enough in rolling back the ACA, also known as Obamacare.
The level of opposition became clear over the July 4 recess, as senators retreated to their home states for holiday festivities and, in a few cases, meetings with constituents. And while moderates, including Sen. Susan Collins, R-Maine, and staunch conservatives, such as Sen. Rand Paul, R-Ky., maintained their skepticism over the proposal, support from rank-and-file members also began to wilt.
Sens. Jerry Moran, R-Kans., and John Hoeven, R-N.D., both came out in opposition to the bill as written in recent days, marking a sign that Senate Majority Leader Mitch McConnell, R-Ky., has yet to win over some lawmakers initially thought to be allies.
Moran said in a town hall last week that he had reservations about cuts to Medicaid, saying it would harm states like Kansas that had not expanded the program under the ACA.
“We get punished and pay a higher price for states that did it differently, so that’s troublesome for me,” he said, adding that he also had reservations that the bill would take away coverage for those with preexisting conditions.
Other lawmakers, from states that had opted to increase Medicaid enrollment, are skeptical of the cuts in the Senate bill, which are even deeper than those in the health care law approved by the House earlier this session.
In an effort to appease these moderates, including Collins and Sen. Dean Heller, R-Nev., McConnell may opt to preserve a key tax hike in the ACA that the first bill initially eliminated.
Keeping the 3.8 percent net investment tax on households making more than $250,000 a year would allow McConnell to soften some of the cuts to Medicaid and mute criticism from Democrats that the Senate bill gives tax breaks for the wealthy while booting low-income Americans off of health insurance.
Such a move could, however, lose McConnell the support of his most conservative members, who are already plotting a strategy to move the bill further to the right. Sens. Ted Cruz, R-Texas, and Mike Lee, R-Utah, are among those who have said they would not support the current version of the bill because it does not go far enough in repealing Obamacare.
Their solution is the so-called Consumer Freedom Amendment. The proposal would allow insurers to offer cheaper plans that don’t conform to the Affordable Care Act’s coverage mandates, as long as the insurers also offer at least one plan that does.
Proponents of the amendment have said it would bring prices down for healthier people, but it could cause market segmentation, with the sickest Americans forced to select more expensive plans that offer more coverage. And while the change could help get conservatives like Cruz, Lee, Paul and Sen. Ron Johnson, R-Wis., on board, it could also alienate moderates.
“[Cruz’s] proposal would lead to unaffordable rates for people with preexisting conditions,” Collins told the Associated Press Monday, adding, “I do not support his plan.”
This delicate balance that McConnell must strike has left some lawmakers skeptical that a vote will happen on the Senate bill.
“My view is that it’s probably going to be dead,” Sen. John McCain, R-Ariz., said Sunday on CBS’ “Face the Nation.” “But I’ve been wrong. I thought I’d be president of the United States. But I fear that it’s going to fail.”
Even McConnell himself said over the recess that if this last effort fails, Republicans will have to reach across the aisle and work with their Democratic colleagues to stabilize the Affordable Care Act’s exchanges.
The pressure is on lawmakers, many of whom have campaigned on the promise to repeal and replace former President Barack Obama’s signature legislative achievement. And President Trump has been egging them on to pass a bill before the August recess. In a tweet early Monday morning, Trump said that he “cannot imagine” that Congress “would dare leave” without delivering a bill to his desk.
Vice President Mike Pence doubled down on that position in a Monday interview with Rush Limbaugh. Pence echoed the stance of Trump and others that the Senate should repeal Obamacare even if it does not have a replacement bill ready.
“If they can’t pass this carefully crafted repeal and replace bill, we ought to repeal only,” Pence said.
In the meantime, McConnell is pushing for a vote on a revised bill to occur as soon as next week. Members are waiting for the Congressional Budget Office to score a series of changes that McConnell is hoping to use to woo hesitant members, including the Cruz amendment. Lawmakers have said that the scores on these proposals will be key in determining their vote on the final legislation; the CBO reports could come later this week or early next week.
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