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Senate Republicans unveil revised healthcare bill
Senate Republican leaders on Thursday unveiled a revised version of their bill to repeal and replace ObamaCare as they race toward a high-stakes vote next week.
The measure includes changes intended to win over additional votes, with leadership making concessions aimed at bringing both conservatives and moderates on board. (READ THE BILL HERE.)
But Senate Majority Leader Mitch McConnell (R-Ky.) is facing a tough task in finding enough votes to pass the bill. Sens. Susan Collins (R-Maine) and Rand Paul (R-Ky.) appear to be firmly against the measure, and one other defection would kill the bill.
Overall, McConnell appears to have shifted the revised bill more toward the conservatives than the moderates.
Importantly, the bill largely keeps the Medicaid sections the same, meaning that deeper cuts to the program will still begin in 2025, and the funds for ObamaCare’s expansion of Medicaid will still end in 2024.
The changes to Medicaid have emerged as a top concern for moderates such as Sens. Rob Portman (R-Ohio), Shelley Moore Capito (R-W.Va.) and Lisa Murkowski (R-Alaska).
The Congressional Budget Office (CBO) found that those Medicaid changes in the original bill would result in 15 million fewer people being enrolled in the program and cut spending by $772 billion over 10 years.
Collins said she still plans to vote against a motion to proceed to the bill, adding that the legislation should move through the normal committee process.
“My strong inclination and current intention is to vote no on the motion to proceed,” Collins told reporters after leaving a briefing on the legislation.
“The only way I’d change my mind is if there’s something in the new bill that wasn’t discussed or that I didn’t fully understand or the CBO estimate comes out and says they fixed the Medicaid cuts, which I don’t think that’s going to happen.”
For the conservatives, the measure includes a version of an amendment from Sens. Ted Cruz (R-Texas) and Mike Lee (R-Utah) aimed at allowing insurers to offer plans that do not meet all of ObamaCare’s regulations, including those protecting people with pre-existing conditions and mandating that plans cover certain services, such as maternity care and mental healthcare.
Conservatives argue the change would allow healthier people to buy cheaper plans, but moderates and many healthcare experts warn that premiums would spike for the sick people remaining in the more generous insurance plans.
Cruz said he will support the bill so long as the provisions he sees as a priority are not changed in amendment votes on the floor.
“If this is the bill, I will support this bill,” Cruz told reporters after a meeting of GOP senators. “Now, if it’s amended and we lose the protections that lower premiums, my view could well change.”
Senate Republicans had vowed to not change the ObamaCare protections for people from being charged more based on their health in their bill, which is why the debate over the Cruz-Lee amendment has been heated.
A Senate GOP aide said Thursday it is possible that the Cruz amendment would not be analyzed by the CBO in time for the vote next week. It is possible the Department of Health and Human Services could provide an alternative analysis.
Lee cautioned that he was not involved in the changes to the proposal, including the amendment, and would have to review the new language before deciding whether to support it.
The bill does include new funding, $70 billion over seven years, aimed at easing costs for those sick people remaining in the ObamaCare plans.
However, the new measure does not boost the generosity of the tax credits, as some moderates wanted. It still replaces ObamaCare’s tax credits to help people afford insurance with a smaller, scaled-down tax credit that provides less assistance.
The Kaiser Family Foundation found premium costs would increase an average of 74 percent for the most popular healthcare plan, given the reduced assistance in the GOP bill.
The new measure will leave in place two ObamaCare taxes on the wealthy, in a departure from the initial bill.
That original measure lacked the support to pass, as more moderate members pointed to the CBO’s finding that 22 million fewer people would have insurance over a decade.
Senate Republicans are now awaiting a new score of the revised legislation from the CBO, which could come early next week.
The new bill does include $45 billion to fight opioid addiction, but moderates such as Capito and Portman who hail from states where the problem is rampant have said they also want changes to the Medicaid portion of the legislation.
Portman said his position on the bill had not changed, but he did not give a clear answer on whether he’d back his party on the procedural vote.
“I’m the same position I’ve been in. I’m looking at the language,” he said.
Capito also said she doesn’t know whether she’ll vote to proceed to the bill.
“We have another meeting this afternoon on the Medicaid cuts,” she told reporters. “I need to really look at it, look at the score; I still have concerns.”
Asked if she would vote for the motion to proceed next week, she said, “Wait and see.”
In a change that could appeal to Murkowski, the bill sets aside 1 percent of the stability funds for states with costs that are 75 percent above the national average, which would benefit high-cost states like Alaska.
The updated Senate health care bill: What you need to know
What the latest Senate health care bill does to Obamacare
| Slimmed-down benefit requirements |  new |
| Opioid funding | new |
| Taxes | new |
| Catastrophic health plans | new |
| Health savings accounts | new |
| Market stabilization | new |
| Traditional Medicaid | changed |
| Pre-existing conditions | changed |
| Medicaid expansion | changed |
| Insurance subsidies | changed |
| Individual mandate |  eliminated |
| Cost-sharing subsidies | eliminated |
| Planned Parenthood funding | eliminated |
The massive Senate GOP shift on pre-existing conditions
https://www.axios.com/the-massive-senate-gop-shift-on-pre-existing-conditions-2458798705.html
- When Senate GOP leaders first presented their plan to the caucus in a PowerPoint presentation, it explicitly said that pre-existing conditions wouldn’t be touched, aides say.
- As recently as two weeks ago, aides said members were surprised and angry to learn that Sen. Ted Cruz’s Consumer Freedom Option would allow plans that didn’t include the Affordable Care Act’s pre-existing conditions protections. (They could only be sold by insurers that also offered plans with the protections.)
- Sen. Bob Corker: “I think people understand that’s got to be protected, and people understand what happened when the House dealt with it and opened it up, and it’s just not something that senators are wishing to do.”
- Sen. Shelley Moore Capito over recess: “I think that reopens an issue that I can’t support, that it would make it too difficult for people with pre-existing conditions to get coverage.”
- Sen. Chuck Grassley last week: “There’s a real feeling that that’s subterfuge to get around pre-existing conditions.”
Now, that resistance is “melting away,” as one Senate Republican aide put it today. “No one wants to be bad guy.”
Indeed, almost seven hours after the revised bill — including the Cruz provision — had been released, no Republican senator had threatened to vote against the bill unless the provision is removed. In fact, Republicans had surprisingly little to say about it.
What the Consumer Freedom Option does:
- It allows insurers that offer ACA-compliant plans to also sell plans that do not comply with ACA regulations, including the law’s essential health benefits and its pre-existing conditions protections.
- Advocates of the bill say that while this could sort sick and healthy people into two different marketplaces, causing premiums to skyrocket for sick people, they’ll be insulated from these costs by premium subsidies and the bill’s stabilization fund.
- Members “don’t realize we are basically creating single payer for sick people,” the GOP aide told me, saying that Republicans’ support is growing because people with pre-existing conditions can still get exchange plans.
- The problem: “If there were hearings, everyone would have a lot more information about Cruz. Right now, Cruz is the only seller of the amendment and he’s the only one with information about the amendment,” said one well-connected GOP lobbyist, who said Cruz’s sales pitch seems to be convincing members to support his idea.
What insurers and experts are saying:
- America’s Health Insurance Plans: “Patients with pre-existing conditions … would potentially lose access to comprehensive coverage and/or have plans that were far more expensive.”
- Scott Serota, president and CEO of the Blue Cross Blue Shield Association: “The ‘Consumer Freedom Option’ is unworkable as it would undermine pre-existing condition protections, increase premiums and destabilize the market.”
- Kaiser Family Foundation: 1.5 million people with pre-existing conditions could have higher premiums under the Cruz amendment.
Yes, but: The conservative groups love it, as it addresses the ACA regulations that weren’t fully addressed in the previous version of the bill. They believe those regulations are driving up the cost of insurance. Stripping the provision could lose these groups’ support.
And Michael Cannon of the libertarian Cato Institute says the provision “would make access to healthcare more secure for patients who develop expensive conditions” — because it would free insurers to introduce a wider variety of health plans and make them less likely to leave the markets.
Why a Bipartisan Health Care Compromise Is Simply a Delusion
Senate Republicans bought themselves a little more time this week to deliver on their top agenda item, repealing and replacing Obamacare. Majority Leader Mitch McConnell agreed to trim two weeks off the August recess, responding to a number of calls within his caucus to expand the legislative calendar. The big question, however, is whether it will help and whether there are any options left if it doesn’t.
McConnell has called a meeting Thursday morning with the entire GOP caucus, presumably to roll out the new version of the Better Care Reconciliation Act (BCRA). Sen. Pat Toomey first mentioned the new effort on Monday, predicting that it would bridge the gap between moderates and conservatives within Republican ranks. “There’s still a shot at getting to 50 [votes],” Toomey said on CNBC’s Squawk Box.
It got off to a bad start even before the big reveal. Sen. Rand Paul wrote a blistering op-ed at Breitbart on Wednesday to announce his rejection of the new version of the BCRA, calling it “worse than Obamacare-lite.” Paul accused Republicans of bolstering federal authority over health insurance, retaining too much of the Affordable Care Act’s taxes and regulations, and “creating a giant insurance bailout superfund.” Paul decried the lost opportunity to fulfill pledges made during the past seven years to repeal Obamacare “root and branch.”
Unfortunately, the opportunity to repeal Obamacare “root and branch” came and went five years ago when Republicans failed to beat Barack Obama’s re-election bid. Too much of Obamacare has already been implemented, which has distorted the markets considerably and recast political incentives. Donald Trump himself recognized this in his presidential campaign, promising that the repeal of Obamacare would come with a replacement program that ensured the least amount of disruption possible.
Republican Senators from rural states worry that a flat-out repeal without any transitional support would hit hard in the very areas where they won elections. A straight repeal would require 60 votes as it goes beyond merely budgetary issues, but it would be unlikely to get close to 50 even if it qualified for the reconciliation process.
Trump made it clear in an interview with CBN’s Pat Robertson on Wednesday that he expects the Senate to act on Obamacare. “Mitch has to pull it off,” Trump said, noting that Obamacare was “a failed experiment,” and that Congress had to act. When Pat Robertson asked what would happen if McConnell failed to deliver a repeal bill, the president replied, “I think it would be very bad. I will be very angry about it, and a lot of people will be upset.”
That may be a rare case of understatement from President Trump. A new poll from Politico and Morning Consult shows that two-thirds of Republican voters expect the GOP to honor their promises and repeal Obamacare. Forty percent of voters overall want a repeal bill passed (with 47 percent opposed, it should be noted), which makes for considerable pressure on Senate Republicans. Interestingly, though, the poll also shows that a majority of GOP voters (54 percent) want Republicans to work with Democrats on a bipartisan reform of the system.
It’s not the first time that’s been suggested. Mitch McConnell warned last week that a failure of Republicans to coalesce around a solution would force him to work with Democrats on temporary fixes for Obamacare exchanges. John McCain and Bill Cassidy both called for negotiations across the aisle last week, with McCain saying, “That’s what democracy is supposed to be all about.”
Don’t expect to find any escape hatch in that direction, though. Toomey called this option “grim” on Monday for a reason; Democrats are fighting to protect Obamacare. They could get Senate Minority Leader Chuck Schumer to work with them “as long as nothing gets repealed, the mandates don’t go away, taxes remain in place, and Medicaid stays on a completely unsustainable fiscal train wreck,” Toomey told CNBC.
Even renegade Democratic centrists don’t offer much hope for peeling off enough for a bipartisan compromise. A handful of House Democrats issued a proposal called, “Solutions over Politics” (SoP) to redirect the debate over health-care reform. “We are proposing real, concrete solutions that will stabilize and improve the individual market,” Rep. Kurt Shrader (D-OR) declared, “making Obamacare work better for everyone, and getting us closer to universal coverage for all Americans.”
Unfortunately, this agenda looks very close to the same laundry list Schumer has pushed in the Senate. Shrader wants a permanent subsidy for insurance companies to make up for the losses they incur, guaranteeing a perpetual river of red ink from Obamacare. The original reinsurance funds were time-limited because Democrats insisted that markets would stabilize after the first few years and would become self-sufficient. This “solution” concedes the Republican argument that Obamacare is unsustainable without heavy government spending, and is structurally unsound.
Even where it differs from the official Democratic Party line, the SoP proposal doesn’t stray very far. It endorses health-savings accounts (HSAs), but only for “plans compliant with the ACA,” where Republicans want to expand the use of HSAs to allow for non-compliant innovation. The SoP proposal retains all of the mandates while allowing for “catastrophic health insurance plans … for younger enrollees,” without acknowledging that Obamacare’s high-deductible plans already act in practical terms as catastrophic coverage at high premium levels. Their solution for poor enrollment figures is not to repeal the unsound structure of mandates and narrow choice of coverages that creates it, but “robust marketing around open enrollment periods.”
Simply put, there is no basis for compromise between one side that sees Obamacare as an abject failure in need of repeal, and another that sees a lack of government funding and a better PR campaign as the only problems in need of solutions.
No, Republicans must do this on their own if it is to be done at all. That is the Hobson’s choice that faces Senate Republicans, and the sooner they realize it, the quicker they will find a way to move forward on a solution. If they don’t, Trump will almost certainly be proven prescient when voters weigh in on seven years of broken promises.
AHIP: Cruz proposal would destabilize the ACA exchanges
The health insurance industry’s largest trade group is warning that a proposed amendment to the Senate’s healthcare bill could not only destabilize the individual marketplaces, but also harm patients with pre-existing conditions.
The amendment, introduced by Sen. Ted Cruz, R-Texas, would allow insurers to sell health plans that aren’t compliant with the Affordable Care Act’s rules in any given state as long as they sell at least one ACA-compliant plan on that state’s exchange.
Cruz and the amendment’s other supporters in the Senate said the concept would allow insurers to offer a wider variety of coverage options and help lower premiums. Senate Majority Leader even reportedly went so far as to ask the Congressional Budget Office to score the proposal.
But the idea also has plenty of critics, including America’s Health Insurance Plans (AHIP).
In a document (PDF) posted on its website, the trade group said that allowing health insurance products to be governed by different rules would effectively “fracture and segment insurance markets into separate risk pools and create an un-level playing field that would lead to widespread adverse selection and unstable health insurance markets.”
The trade group pointed out that part of the exchanges’ current woes stemmed from the Obama administration’s transitional policy, which allowed individuals to renew their non-ACA-compliant plans. In states that opted to adopt this policy, actuaries estimated that exchange market premiums were an average of 10% higher.
Cruz’s amendment, which would essentially make that transitional policy permanent, “would create even greater instability,” AHIP said.
The fact that the proposal would require insurers to also offer an ACA-compliant plan, the group said, is not enough to protect consumers with pre-existing conditions or higher-than-average healthcare costs. The ACA’s consumer protection provisions, such as guaranteed issue and community rating, AHIP notes, “only work if there is broad participation to assure stable markets and affordable premiums,” which wouldn’t be the case under Cruz’s proposal.
In fact, a newly released analysis from the Kaiser Family Foundation estimated that the amendment could result in 1.5 million people with pre-existing conditions facing higher premiums.
Finally, it’s simply not practical to maintain a single risk pool if all health plans don’t have to provide coverage for the same benefits, AHIP stated, adding that the Cruz amendment also would make programs like risk adjustment “unworkable.”
Revised Senate healthcare bill includes version of Ted Cruz’s controversial amendment
Despite opposition from the health insurance industry, Senate Republicans’ revised healthcare bill includes a version of a proposal that would allow the sale of slimmed-down individual market plans.
A new discussion draft (PDF) of the Better Care Reconciliation Act includes a provision based on an amendment proposed by Sen. Ted Cruz, R-Texas. The provision would allow insurers to sell plans that don’t comply with the Affordable Care Act’s benefits requirements as long as they sell at least one plan in that state that does comply.
America’s Health Insurance Plans, which has largely avoided passing judgement on the GOP’s ACA repeal measures, said this week the Cruz amendment would “would create even greater instability” in the individual marketplaces. A separate report estimated that it could result in 1.5 million people with pre-existing conditions facing higher premiums.
Perhaps in a nod to these concerns, the Senate’s revised measure includes an additional $70 billion to help states lower insurance premiums. States with exceptionally high premiums would also get some assistance, as the Kaiser Family Foundation’s Larry Levitt points out:
The reworked Senate bill also maintains the ACA’s taxes on wealthy individuals, and it adds $45 billion in funding to fight the opioid crisis.
Though the cuts to Medicaid that have concerned moderates are left largely intact in the revised bill, the new version does offer some Medicaid funding flexibility for states in the event of a public health crisis. States would also be able to add the newly eligible Medicaid population to coverage under the block grant funding option.
HENRY KOTULA 