Senate Republicans ended a demoralizing week on Thursday with their leaders determined to press ahead with a vote to begin debating health care next week, but with little progress on securing the votes and no agreement even on which bill to take up.
With President Trump urging them to move forward on their seven-year quest to erase the Affordable Care Act, Republican senators on Thursday still had not decided whether to revive a proposal to replace former President Barack Obama’s health care law with one of their own, or to simply repeal it and work on a replacement later.
The choice is unpalatable: The nonpartisan Congressional Budget Office said on Thursday that the latest version of the bill to repeal and replace the health law would increase the number of people without health insurance by 15 million next year and by 22 million in 2026. Those figures are the same as the estimates in the budget office’s previous analysis, despite numerous changes to the bill intended to win votes.
On the other hand, if senators opted simply to repeal the existing law, the budget office said on Wednesday, 32 million more people would be uninsured in 2026 compared with current law.
The majority leader, Senator Mitch McConnell of Kentucky, remained unswerving in his drive toward a vote next week on a procedural motion to begin debating health care. But he has not specified which version of the legislation he intends to put before the Senate. In effect, he is asking 50 senators to roll the dice and hope they land on an option they can work with.
“You can’t debate something that you don’t initiate the debate on,” said Senator John Cornyn of Texas, the No. 2 Senate Republican. “And everybody can offer endless amendments, so if anybody’s got a better idea, they can offer that and get a vote on it. And in the end, 50 people are going to decide whether we’re going to have an outcome or not.”
Asked whether senators want to know the plan before they vote, Mr. Cornyn said that was “a luxury we don’t have.” (He later wrote on Twitter that it was “hard to predict” the final legislation because of the amendment process.)
The release of the budget office’s analysis capped a tumultuous period that began with the seeming collapse of Mr. McConnell’s health care bill. Then Mr. Trump’s changing demands added to the disarray. Finally, the week turned heavy-hearted with the news that Senator John McCain, Republican of Arizona, has brain cancer.
It remained far from clear whether Republicans would be able to assemble the votes to begin debate, let alone coalesce around legislation to repeal the health law and, possibly, to replace it.
“I want us to remember that our attempt here is to lower the cost of health care; it’s not just about getting 50 votes,” said Senator Bob Corker, Republican of Tennessee. Mr. Corker said a repeal-only measure now seemed like the best course of action, and he expressed concern about the continuing negotiations for a broader bill that would replace the health law.
“I’m beginning to fear that it’s taking on some of the same characteristics that Obamacare took on when it was passed,” Mr. Corker said. “It’s beginning to feel a little bit like a bazaar, if you will, where, ‘Let’s throw $50 billion here, $100 billion there.’”
To start debate, Mr. McConnell can afford to lose only two Republican votes — or just one if Mr. McCain is absent. It was unclear on Thursday whether Mr. McCain would be able to travel to Washington in the near future, and Senator Susan Collins of Maine remained firmly in opposition, barring a drastic change in the direction of the Senate’s efforts. She said the Senate should hold hearings on the problems with the Affordable Care Act and try to produce bipartisan bills on the subject.
“As long as we are fundamentally changing Medicaid and taking some $700 billion out of the program, I do not see myself voting for a bill that does that,” Ms. Collins said. “And to do that without holding a single hearing on what the implications would be for some of our most vulnerable citizens, for our rural hospitals and our nursing homes, is not an approach that I can endorse.”
The budget office said the latest version of the Senate bill would cut projected federal spending on Medicaid by $756 billion in the coming decade, and in 2026, it said, 15 million fewer people would be enrolled in Medicaid, compared with current law.
Senators from states that have expanded Medicaid worry about the loss of coverage. To address those concerns, Republican leaders are considering a proposal to add $200 billion to the bill to help reduce the costs of private insurance for people who lose Medicaid.
“It sounds like a lot of money, and it is a lot of money,” said Senator Christopher S. Murphy, Democrat of Connecticut. But he said it represented just a slice of the funds that are being cut and described it as only “a temporary Band-Aid on a much bigger problem.”
The budget office has yet to take into account a provision that would allow insurers to offer low-cost, stripped-down insurance plans, an idea that has been pushed by Senator Ted Cruz, Republican of Texas, and is critical to winning his vote and that of another conservative, Mike Lee of Utah.
Mr. Cruz’s proposal was included in a version of the bill released last week, but it has been assailed by the insurance industry. The provision was omitted from the latest version of the bill that was released on Thursday, but congressional aides said that was because an assessment from the budget office was not ready yet, not because the proposal had been jettisoned.
The budget office did have good news about the latest version’s fiscal impact: It would reduce federal budget deficits by a total of $420 billion over 10 years, about $100 billion more than an earlier version of the legislation. The change resulted mainly from the decision of Senate leaders to keep two taxes on high-income people that were imposed by the Affordable Care Act, but that would have been eliminated under the earlier version.
The latest version of the Senate bill would increase average insurance premiums by about 20 percent next year for a typical “benchmark plan,” the budget office estimated, but would reduce premiums after 2019, so that in 2026 premiums for a benchmark plan would be about 25 percent lower than under current law.
But, the budget office said, the Senate bill could sharply increase deductibles, raising the amount that a person would pay out of pocket for most services before insurance made any contribution. For a single person, it said, the annual deductible could soar to $13,000 in 2026. That could push many lower-income Americans into the ranks of the uninsured.
“Because a deductible of $13,000 would be a large share of their income, many people with low income would not purchase any plan even if it had very low premiums,” the budget office said.
Moreover, the budget office said, even though average premiums for a standard benchmark plan would fall after 2019, many older people would face substantial increases in premiums.
For example, it said, the net premium, after tax credits, for a midlevel “silver plan” for a 64-year-old person with annual income of $26,500 would be $5,500 a year in 2026, more than three times the amount projected under current law.