Tag Archives: ACA Repeal

Senate ObamaCare repeal bill falls in shocking vote

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http://thehill.com/policy/healthcare/344268-senate-defeats-obamacare-repeal-measure

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The Senate rejected a scaled-back ObamaCare repeal bill in the early hours of Friday in a shocking vote that marks a major defeat for GOP leaders and the seven-year effort to repeal the health law.

The Senate voted 49-51 against the “skinny” bill, which would have repealed ObamaCare’s individual and employer mandates and defunded Planned Parenthood.

Sen. John McCain (R-Ariz.) provided the crucial vote against the bill, alongside GOP Sens. Susan Collins (Maine) and Lisa Murkowski (Alaska).

A succession of Republicans attempted to appeal to McCain, as well as Murkowski, on the Senate floor while the preceding vote was held open long after it usually would have closed.

Vice President Pence, and Sen. Jeff Flake, also of Arizona, were among those who went to talk to McCain.

“We all wanted to try to get to a positive outcome,” Murkowski said after the vote. “It’s very disappointing that we weren’t able to.”

McCain, who returned to the Senate this week after learning he had brain cancer last week, said in a statement after the vote that he wanted to go back and use the committee process, while working with Democrats on healthcare.

“We must now return to the correct way of legislating and send the bill back to committee, hold hearings, receive input from both sides of the aisle, heed the recommendations of nation’s governors, and produce a bill that finally delivers affordable health care for the American people,” McCain said in the statement.

The so-called “skinny” bill was cast by Republicans as a way to keep their repeal hopes alive and get to negotiations with the House.

Now, it appears that Republican hopes of repealing ObamaCare have been quashed.

In a speech from the Senate floor early Friday morning after the surprise failed vote, Majority Leader Mitch McConnell (R-Ky.) said “it is time to move on.”

“What we tried to accomplish for the American people was the right thing for the country,” McConnell said. “I think the American people are going to regret that we couldn’t find another way forward.”

Moving forward, McConnell invited Democrats to offer their ideas, but he seemed skeptical, saying that “bailing out insurance companies” would not be acceptable.

“Now I think it’s appropriate to ask, what are their ideas?” McConnell said. “It’ll be interesting to see what they suggest as the way forward.”

Democratic requests include providing funding to lower premiums for high-cost enrollees, known as “reinsurance,” and guaranteeing key ObamaCare payments, known as cost-sharing reductions.

President Trump reacted on Twitter, saying the three Republicans and Democrats who all voted against the bill had let the country down.

The president has threatened to cancel the reinsurance payments, and in a separate tweet appeared to do so again. “As I said from the beginning, let ObamaCare implode, then deal. Watch!” Trump tweeted.

Sen. John Thune (R-S.D.) pointed to hearings that could be held by Sen. Lamar Alexander (R-Tenn.) with Sen. Patty Murray (D-Wash.) in the health committee.

“We’re not adverse to that, I just don’t have high hopes that we’re really going to get anything that solves the problem that we think exist with ObamaCare,” Thune said.

Ahead of the vote, many GOP senators admitted that the measure was not good policy, but, in a highly unusual situation, said they were voting for it simply to advance the process and set up a negotiation with the House on a new bill, in what is known as a conference committee.

But some Republicans harbored fear that a conference committee could fail, and the House could eventually just take up the scaled-down bill and send it to the president.

Insurers and many healthcare experts warned that by repealing the mandate to have insurance without a replacement, the bill would significantly destabilize health insurance markets and spike premiums.

The Blue Cross Blue Shield Association warned of “steep premium increases and diminished choices that would make coverage unaffordable and inaccessible.”

The Congressional Budget Office found that the bill would result in 16 million more uninsured people and roughly 20 percent higher premiums, largely from repealing the mandate to have insurance.

Republicans pointed out many of those people would choose not to buy insurance, without the mandate.

Sen. Lindsey Graham (S.C.), a Republican, warned that if the bill became law it would “collapse the individual market.” But he said he received assurances from Speaker Paul Ryan (R-Wis.) that the House would not just pass the bill and there would be a conference committee.

The process for sending the bill to the floor was highly unusual. GOP leaders released the text of the bill just hours before the final vote, a decision widely denounced by Democrats.

With the bill’s failure, some expressed hope about bipartisanship.

“I hope so,” said Sen. Bill Cassidy (R-La.). “I have tried in the past as has [Collins] to have a dialogue. It hasn’t worked. Maybe this had to happen to begin to have a conversation.”

McCain casts crucial vote to kill ‘skinny’ ObamaCare repeal

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http://thehill.com/homenews/senate/344270-mccain-votes-to-kill-gops-skinny-backup-obamacare-repeal-plan

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Sen. John McCain (R-Ariz.) cast the crucial surprise vote that killed the last-resort Senate Republican ObamaCare repeal bill early Friday morning in a shocking moment that at least temporarily ended the GOP’s hopes of eliminating the former president’s signature law.

Voting shortly after midnight, McCain — who returned to the Senate on Tuesday after undergoing emergency surgery related to brain cancer — joined GOP Sens. Susan Collins (Maine) and Lisa Murkowski (Alaska) in opposing the measure that would have repealed key parts of ObamaCare.

McCain cast the “no” vote two days after a dramatic return to the Senate floor during which he called on his colleagues to work together on major issues such as healthcare reform, which has long been a Senate tradition until the upsurge of partisanship in recent years.

The vote cements McCain’s status as the Senate’s maverick, a role he relished earlier in his career when President George W. Bush occupied the White House.

McCain, who was defeated in the 2008 presidential election that brought Barack Obama to power, has emerged this year as one of President Trump’s most outspoken critics in Congress.

The two feuded during Trump’s presidential campaign; at one point, Trump mocked McCain for being a prisoner of war, saying he liked war heroes who were not captured.

That history simply added to the drama of Friday morning’s moment.

The bare-bones healthcare proposal, dubbed the “skinny” repeal because it left untouched big sections of ObamaCare, would have resulted in 16 more million people being without insurance in a decade, according to the Congressional Budget Office (CBO).

The CBO also estimated that it would increase premiums by 20 percent compared to current law.

Given those statistics, there was speculation early in the week about whether McCain would vote with his party given his own health news.

McCain did vote with Republicans to start debate on Tuesday, but warned he was opposed to the current version of their repeal-and-replace legislation.

He warned on Thursday that he did not want the skinny bill to become law, and asked for assurances from House Speaker Paul Ryan (R-Wis.) that there would be a conference and that the House would not just pick up the skinny bill and pass it.

Other senators aligned with him appeared reassured by a Ryan statement and backed the skinny bill. But McCain appeared to feel differently with his own vote.

Senate Majority Leader Mitch McConnell (R-Ky.) pushed the skinny bill as a backup proposal after Republicans failed to agree on a bigger repeal that repealed and replaced the pillars of ObamaCare or a repeal-only measure that passed both chambers in 2015.

He appeared almost distraught after McCain’s surprise vote and seemed close to choking up on the floor after falling short of his promise to repeal ObamaCare.

“This is clearly a disappointing moment,” he said.

“I regret that our efforts were simply not enough this time. Now, I imagine many of our colleagues on the other side are celebrating. Probably pretty happy about all this. But the American people are hurting, and they need relief.”

Many Republican senators, however, did not support the substance of the so-called skinny legislation. They decided to vote for it as a way to prolong the healthcare negotiation by setting up a conference negotiation with the House.

Still, McCain’s vote surprised many Republicans including Sen. Bill Cassidy (La.), who said he thought the Arizona Republican was in favor of the legislation.

Sen. Ron Johnson (R-Wis.) told reporters, “I’m shocked at this.”

Vice President Pence was spotted lobbying McCain on the Senate floor shortly before the crucial vote. He also worked on Collins while other GOP leaders focused on Murkowski.

But those efforts fell short.

Senate Republican Conference Chairman John Thune (R-S.D.) said McCain was wrestling with the decision all day but in the end would not budge.

“He had made up his mind and I’m not sure there was much that could have been done about it,” he said.

McCain declined to “go through my thought process” when reporters asked him about his vote.

Whatever he may have thought about, the diagnosis of brain cancer he received from doctors last week hovered over his decision.

None of his colleagues mentioned it explicitly, but many Democrats thought it would be a sad irony if the lawmaker voted for legislation that CBO projected would cause 16 more million people to be without health insurance at a time when he was depending on doctors in his fight against cancer.

In addition, McCain was never a big fan of the Senate healthcare reform effort, which would have cut billions of dollars in Medicaid funding for his home state of Arizona, one of 30 states that expanded enrollment under ObamaCare.

He raised Republican suspicions and Democratic hopes shortly before the historic vote when he declined to tell reporters how he would vote on the latest idea from the GOP leadership, the so-called “skinny” repeal.

One Republican leadership source predicted earlier in the day that it had a “nine out of 10” chance of passing.

But McCain’s defection became apparent when he began huddling with Democrats on the Senate floor.

He complained earlier this month after Senate GOP leaders left out three Medicaid-related amendments that Arizona Gov. Doug Ducey (R) asked to be included in the bill.

McCain joined GOP Sens. Lindsey Graham (S.C.), Ron Johnson (Wis.) and Cassidy at a press conference a few hours before the vote in which they asked for assurances from House GOP leaders that the “skinny” bill would be revised substantially in a conference negotiation with the House.

Ryan tried to provide some assurance by telling senators that he was willing to work with them, but a Ryan spokesperson earlier in the day described a conference negotiation as an “option” but not a certainty.

“If moving forward requires a conference committee, that is something the House is willing to do,” Ryan said in a statement.

But McCain told reporters that pledge did not go far enough.

“I would like to have the kind of assurances he did not provide,” he said.

Parliamentarian issues warning on another GOP healthcare proposal

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Parliamentarian issues warning on another GOP healthcare proposal

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The Senate parliamentarian advised senators Thursday that another GOP healthcare proposal will need 60 votes for passage because it violates Senate rules.

The GOP’s repeal and replace plan, which failed on the floor Tuesday, contained a provision that would allow states to waive some ObamaCare requirements, including one that says insurers must cover 10 certain benefits in all of their plans.

But the parliamentarian advised that the language would violate the rules of reconciliation, the fast track budget maneuver Republicans are using that only needs 51 votes and is immune to Democratic filibuster.

Because the state waivers language violates these rules, it would need 60 votes, which is impossible without Democratic support.

The parliamentarian has already saidthat a number of other provisions could be stripped out.

These provisions, which are part of the GOP’s failed repeal and replace bill, could still be added to whatever healthcare bill Congress passes.

Republicans want to push through the Senate a “skinny repeal” bill that eliminates ObamaCare’s insurance mandates and some taxes.

That bill may then go to conference with the House, where more language could be added, including these provisions that are revised to meet Senate rules.

It’s not yet clear how the state waivers could be changed to follow Senate rules.

States Have Already Tried Versions Of ‘Skinny Repeal.’ It Didn’t Go Well

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http://www.npr.org/sections/health-shots/2017/07/27/539588546/states-have-already-tried-versions-of-skinny-repeal-it-didn-t-go-well?utm_source=&utm_medium=email&utm_campaign=10058

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Betting that thin is in — and might be the only way forward — Senate Republicans are eyeing a “skinny repeal” that would roll back an unpopular portion of the federal health law. But health policy analysts warn that the idea has been tried before, and with little success.

Senators are reportedly considering a narrow bill that would eliminate the Affordable Care Act’s “individual mandate,” which assesses a tax on Americans who don’t have insurance. The bill would also eliminate the ACA’s penalties for some businesses – those that have 50 or more workers and fail to offer their employees health coverage.

Details aren’t clear, but it appears that — at least initially — much of the rest of the 2010 health law would remain, under this strategy, including the rule that says insurers must cover people who have pre-existing medical problems.

In remarks on the Senate floor Wednesday, Sen. Minority Leader Charles Schumer, D-N.Y., said that “we just heard from the nonpartisan Congressional Budget Office that under such a plan … 16 million Americans would lose their health insurance, and millions more would pay a 20 percent increase in their premiums.” The CBO posted its evaluation of the GOP’s proposed plan Wednesday evening.

Earlier in the day, some Republicans seemed determined to find some way to keep the health care debate alive.

“We need an outcome, and if a so-called skinny repeal is the first step, that’s a good first step,” said Sen. Thom Tillis, R-N.C.

Several Republican senators, including Dean Heller of Nevada and Jeff Flake of Arizona, appear to back this approach, according to published reports. It is, at least for now, being viewed as a step along the way to Republican health reform.

“I think that most people would understand that what you’re really voting on is trying to keep the conversation alive,” said Sen. Bob Corker, R-Tenn. “It’s not the policy itself … it’s about trying to create a bigger discussion about repeal between the House and Senate.”

But what if, during these strange legislative times, the skinny repeal were to be passed by the Senate and then go on to become law? States’ experiences with insurance market reforms and rollbacks highlight the possible trouble spots.

Considering the parallels

By the late 1990s, states such as Washington, Kentucky and Massachusetts felt a backlash when some of the coverage requirement rules they’d previously put on the individual market were lifted. “Things went badly,” said Mark Hall, director of the health law and policy program at Wake Forest University.

Premiums rose and insurers fled these states, leaving consumers who buy their own coverage (usually because they don’t get it through their jobs) with fewer choices and higher prices.

That’s because — like the Senate plan — the states generally kept popular parts of their laws, including protections for people with pre-existing conditions. At the same time, they didn’t include mandates that consumers carry coverage.

That goes to a basic concept about any kind insurance: People who don’t file claims in any given year subsidize those who do. Also, those healthy people are less likely to sign up, insurers said, and that leaves insurance companies with only the more costly policyholders.

Bottom line: Insurers end up “less willing to participate in the market,” said Hall.

It’s not an exact comparison, though, he added, because the current federal health law offers something most states did not: significant subsidies to help some people buy coverage. Those subsidies could blunt the effect of not having a mandate.

During the debate that led to passage of the federal ACA, insurers flat-out said the plan would fail without an individual mandate. On Wednesday, the Blue Cross Blue Shield Association weighed in again, saying that if there is no longer a coverage requirement, there should be “strong incentives for people to obtain health insurance and keep it year-round.”

Individual mandate is still unpopular in voter polls

About 6.5 million Americans reported owing penalties for not having coverage in 2015.

Polls consistently show, though, that the individual mandate is unpopular with the public. Indeed, when asked about nine provisions in the ACA, registered voters in a recent Politico/Morning Consult poll said they want the Senate to keep eight, rejecting only the individual mandate.

Even though the mandate’s penalty is often criticized as not strong enough, removing it would still affect the individual market.

“Insurers would react conservatively and increase rates substantially to cover their risk,” said insurance industry consultant Robert Laszewski.

That’s what happened after Washington state lawmakers rolled back rules in 1995 legislation. Insurers requested significant rate increases, which were then rejected by the state’s insurance commissioner. By 1998, the state’s largest insurer — Premera Blue Cross — said it was losing so much money that it would stop selling new individual policies, “precipitating a sense of crisis,” according to a study published in 2000 in the Journal of Health Politics, Policy and Law.

“When one pulled out, the others followed,” said current Washington Insurance Commissioner Mike Kreidler, who was then a regional director in the federal department of Health and Human Services.

The state’s individual market was volatile and difficult for years after. Insurers did come back, but won a concession: For a time, the insurance commissioner lost the power to reject rate increases. Kreidler, first elected in 2000, reclaimed that authority.

Predicting the effect of removing the individual mandate is difficult, although Kreidler said he expects the impact would be modest, at least initially. Subsidies that help people purchase insurance coverage — if they remain as they are under current law — could help blunt the impact. But if those subsidies are reduced — or other changes are made that further drive healthy people out of the market — the impact could be greater.

“Few markets can go bad on you as fast as a health insurance market,” said Kreidler.

As for employers, dropping the requirement that those with 50 or more workers must offer health insurance or face a financial penalty could mean some workers would lose coverage. But their jobs might be more secure, said Joseph Antos, a health care economist and resident scholar at the American Enterprise Institute.

That’s because the requirement under the ACA meant that some smaller firms didn’t hire people or give workers more than 30 hours a week — the minimum needed under the ACA to be considered a full-time worker who qualified for health insurance.

The individual mandate, he added, may not be as much of a factor in getting people to enroll in coverage as some think, because the Trump administration has indicated it might not enforce it anyway — and the penalty amount is far less than most people would have to pay for health insurance.

However, the individual market could be roiled by other factors, Antos said.

“The real impact would come if feds stopped promoting enrollment and did other things to make the exchanges [— the state and federal markets through which insurance is offered —] work more poorly.”

How Many People Across America Are at Risk of Losing Their Health Insurance?

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Between 2010 and 2015, more than 19 million people in the United States gained health insurance, mostly through key provisions under the Affordable Care Act, according to an analysis by the Urban Institute.

Many of the newly insured were not poor enough to qualify for Medicaid but too poor to buy their own coverage. Others were shut out because of pre-existing conditions.

These groups and others make up the millions that the Congressional Budget Office says could lose their coverage under the Republican plans to repeal and possibly replace the Affordable Care Act.

“All of the elements that enabled more people to get insurance under Obamacare — protections for pre-existing conditions, the expansion of Medicaid and subsidies to make insurance more affordable — are potentially at risk under the various options the Senate is debating,” said Larry Levitt, a policy expert at the Kaiser Family Foundation.

Under six Republican proposals that the Congressional Budget Office had analyzed, the number of uninsured in America would increase by 22 million to 32 million people in 10 years — essentially erasing much of the gains made under the Affordable Care Act. A C.B.O. analysis released Wednesday night showed that a “skinny” repeal measurebeing floated by lawmakers would increase the number by 16 million in 10 years.

“It’s a dramatic understatement to say there’s uncertainty about where this debate will end up,” Mr. Levitt said.

Healthcare groups blast skinny repeal, warn premiums will spike

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Healthcare groups blast skinny repeal, warn premiums will spike

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Healthcare groups are coming out against the Senate GOP’s plan to pass a scaled-down ObamaCare repeal bill, saying it would spike insurance premiums.

The American Medical Association, the Blue Cross Blue Shield Association and the American Cancer Society Cancer Action Network are among the range of healthcare groups blasting the bill.

The scaled-down, “skinny” repeal bill would repeal ObamaCare’s mandate for people to have insurance, which insurers and other groups warn would lead to a sicker group of enrollees and spiking premiums.

The Blue Cross Blue Shield Association warned of “steep premium increases and diminished choices that would make coverage unaffordable and inaccessible.”

“Eliminating the mandate to obtain coverage only exacerbates the affordability problem that critics say they want to address,” said Dr. David Barbe, president of the American Medical Association.

“We again urge the Senate to engage in a bipartisan process — through regular order — to address the shortcomings of the Affordable Care Act and achieve the goal of providing access to quality, affordable health care coverage to more Americans,” Barbe said.

The Congressional Budget Office previously found that repealing the individual mandate would lead to 15 million more uninsured people and cause premiums to increase by about 20 percent.

Republican senators argue the scaled-down repeal bill will never actually become law, and is just a way to set up negotiations with the House on a larger plan. But the House is making no guarantees that it won’t simply vote on the bill and send it to the president.

“The continuing effort by Senate leaders to figure out by trial and error some bill that might gain the needed 50 votes to pass is a threat to millions of Americans including cancer patients and survivors who must have comprehensive coverage in order to access prevention and medical treatment,” the American Cancer Society Cancer Action Network said in a statement.

“The legislation could cause the individual insurance market to collapse putting millions of American families at financial risk,” the cancer group said.

In addition to repealing the individual mandate, the skinny bill would also defund Planned Parenthood, cut the ObamaCare prevention and public health fund, and repeal the employer mandate.

Many healthcare groups have been strongly opposed to the GOP effort to repeal ObamaCare throughout the process, instead urging a bipartisan approach.

Medicaid cuts had been a major focus, though those are not be included in the current bill.

Regardless, America’s Essential Hospitals, which is strongly opposed to Medicaid cuts, said it is still opposed to the “skinny bill.”

“While it doesn’t directly affect Medicaid, it still would badly undermine coverage and access by destabilizing the private marketplace,” Bruce Siegel, the group’s president, said in a statement.

The AARP, a powerful senior group, also warned against it.

“The bill will leave millions uninsured, destabilize the health insurance market and lead to spikes in the cost of premiums,” it wrote in a letter to congressional leaders.

“AARP will inform our members and the public how their Senators voted,” the letter added.

Four GOP senators threaten to block ‘skinny’ repeal

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Four GOP senators threaten to block ‘skinny’ repeal

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Four GOP senators — enough to kill the legislation — say they need hard assurances from House Speaker Paul Ryan that a “skinny” ObamaCare repeal bill won’t be Congress’s final product before they’ll vote for it.

Sens. John McCain (Ariz.), Lindsey Graham (S.C.), Ron Johnson (Wis.) and Bill Cassidy (La.) said Thursday evening they are prepared to vote against a skinny repeal unless they get a guarantee it will go to a conference committee with the House.

“There’s increasing concern on my part and others that what the House will do is take whatever we pass” and pass it without making changes, Graham said.

“The skinny bill as policy is a disaster. The skinny bill as a replacement for ObamaCare is a fraud,” he said. Graham added that if the skinny bill passes the House, the GOP will own the collapse of ObamaCare.

“I’d rather get out of the way and let it collapse than have a half-assed approach where it is now our problem,” he continued.

If the skinny bill were to become law, insurers and other healthcare groups have warned it could cause premiums in Obamacare’s insurance markets to skyrocket.

Graham said a conference committee would buy time for the Congressional Budget Office (CBO) to score proposals from himself and Cassidy, as well as by Sen. Rob Portman (Ohio) and Ted Cruz (Texas).

When asked how he’d know any assurance from House leadership is ironclad, Graham said, “It’s like pornography, you know it when you see it.”

If the Senate does pass a bill, both chambers would have to approve whatever emerges from the House-Senate conference. Alternatively, the House could simply approve the Senate’s skinny bill — a prospect that prompted the press conference from the four GOP senators.

Nothing has been determined yet in the House; GOP leaders appear to be keeping their options open and could call up the bill any time between now and Tuesday.

Senate Majority Whip John Cornyn (R-Texas) said he has had no formal assurances from the House, but has every expectation a conference committee will be called.

“There has been some communication in which it has been reported to me that Paul Ryan said the House is preparing to go to conference,” Cornyn said, noting, “I have not talked to Paul Ryan. The Senate doesn’t determine whether the House goes to conference.”

A spokeswoman for Ryan said the House hadn’t yet decided its course of action.

“Conference Committee is one option under consideration and something we’re taking steps to prepare for should we choose that route after first discussing with the members of our conference,” AshLee Strong said.

GOP leaders have not yet revealed their scaled-down measure, but it is expected that it would repeal the employer and individual mandates from ObamaCare.

In another key provision to win conservative support, it would also block federal funding for Planned Parenthood, which provides abortion services. The skinny bill could also cut ObamaCare’s prevention and public health fund, while adding money for community health centers, sources said.

It would not cut Medicaid, which has been a concern for centrist Republicans. However, conservatives could add the Medicaid cuts back into the bill during a conference committee.

It’s not clear when the Senate will take a final vote on the skinny measure, but Republicans can only afford two defections and still rely on Vice President Pence to break the tie.

The bill is expected to be the final amendment at the end of a marathon voting session beginning Thursday evening.

House Majority Leader Kevin McCarthy’s (R-Calif.) office has warned House lawmakers that they should not immediately depart Washington on Friday, in case the Senate does approve a repeal bill.

CBO: 16 million more uninsured under GOP ‘skinny’ repeal

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http://thehill.com/policy/healthcare/344264-cbo-16-million-would-lose-coverage-under-gop-skinny-repeal

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The GOP’s newly released “skinny” repeal of ObamaCare would result in 16 million additional people without insurance by 2026, according to a report by the Congressional Budget Office (CBO) released Thursday night.

The bill, released just hours before its vote Thursday night, would repeal ObamaCare’s individual insurance mandate permanently and its employer mandate for eight years.

The CBO also estimated that premiums in the individual market would increase by 20 percent compared to current law in all years between 2018 and 2026.

The bill would lower the deficit by $135.6 billion in ten years, the CBO estimates. 
The Senate’s scaled-down ObamaCare repeal bill, the Health Care Freedom Act, would also defund Planned Parenthood for a year, repeal the medical device tax for three years and increase contribution limits to Health Savings Accounts for three years.

A vote on the bill is expected after midnight. Lawmakers could then offer amendments to the legislation.

‘Skinny’ Obamacare repeal still lacks votes to pass

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http://www.politico.com/story/2017/07/26/obamacare-repeal-republicans-minimum-240982

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A bare-bones plan picks up some key GOP support, but centrists and conservatives are skeptical.

Even a bare-bones repeal of Obamacare is no sure thing in the Senate.

A handful of key Republican senators who had spurned earlier overtures from GOP leadership endorsed the latest plan to gut Obamacare’s individual and employer coverage mandates and its medical device tax. But several centrists said they’re undecided on the so-called skinny repeal, leaving the GOP in limbo through at least the end of the week.

Jockeying on the scaled-back approach came as the Senate rejected a straight repeal of Obamacare in a 45-55 vote Wednesday. The night before, senators turned aside a comprehensive replacement plan that had been crafted by Senate Majority Leader Mitch McConnell. The roll calls were the latest reminders that GOP leaders’ best hope at this point is just to get something — anything — through the chamber with a bare majority and into a conference with the House.

“Sure. There’s plenty we agree on,” said Senate Majority Whip John Cornyn (R-Texas) late Wednesday when asked whether he can get 50 votes. One challenge for GOP leaders is “trying to explain the concept that we need to do it this way, as opposed to solving all the problems in a Senate bill now.”

Cornyn said broader negotiations on Medicaid reforms and other divisive issues would likely re-emerge in bicameral negotiations with the House. But some Republicans are worried that those talks would revive efforts to wind down a Medicaid expansion that’s benefited their states.

Centrist GOP Sens. Rob Portman of Ohio and Shelley Moore Capito of West Virginia were undecided on the so-called skinny repeal Wednesday. Another Republican from an expansion state, Sen. Dean Heller of Nevada indicated he would back it.

“We’ll see at the end of the day what’s in it, but overall I think I’d support it,” Heller said. He said slashing Obamacare’s Medicaid expansion or its growth rate should be a nonstarter.

Conservatives could be another matter.

“I don’t like it,” Sen. David Perdue of Georgia said of the process. “Because I don’t know where we end up. This whole [health care system] holds together or falls apart in totality. We’ve got a system that is collapsing.”

South Carolina Sen. Lindsey Graham on Tuesday called the possibility of a skeletal plan a “political punt,” but it may be able to clear the narrowly divided chamber. Graham said he would vote for the slimmed-down plan only if House and Senate lawmakers use it to go to conference and come up with a fuller replacement.

Sen. Jeff Flake of Arizona also indicated that he could get on board with the skinny option.

“In Arizona, you have 200,000 people who were paying the [Obamacare insurance mandate] fine and can’t afford insurance,” Flake told reporters. “We gotta have relief to those who, one: can’t find affordable insurance so they have to pay the fine; and, two: even those that can afford to pay the premium, generally can’t afford to utilize the coverage because the deductibles are so high.”

Whether Sen. Mike Lee of Utah can back a trimmed-down proposal “depends how skinny it is,” a spokesman said. But Sen. Rand Paul of Kentucky signaled he could live with the minimalist approach.

“I’ve always said I will vote for any permutation of repeal. Obviously, I want as much as I can get, but I’ll vote for whatever the consensus can be. It’s what I’ve been saying for months: Start on what you can agree on,” Paul said in an interview Wednesday. “Starting small and getting bigger is a good strategy.”

That would leave out the divisive issues of cuts to Medicaid spending and efforts to create a new tax credit system for the individual markets. Republicans can afford to lose just two votes to pass whatever they come up with in the end.

Many Republicans are in the dark about the emerging proposal. And aides said senators were still focused on amendment votes, floor tactics and the chaotic atmosphere, making it difficult to tell what can clinch 50 votes.

“I don’t know what would be in the skinny repeal,” said Sen. Susan Collins of Maine. “Until I see what’s in it, I’m not ruling it out because I don’t know what it would be.”

The Senate also rejected on Wednesday an attempt to send their repeal effort to congressional committees for several days.

Republicans need a score on any proposal from the Congressional Budget Office to vote at a 50-vote threshold. They are aiming for a vote on Friday on their final plan after the unlimited amendment process known as vote-a-rama, which is expected to begin sometime Thursday.

In the final bill, Republicans could try to add more elements than repealing the mandates and device tax, but that could complicate efforts to get a quick CBO score.

“Look for victories where we should find them. In my opinion, the victory will always include: individual mandate repeal, employer mandate repeal and [eliminating] the medical device tax,” said South Carolina Sen. Tim Scott. “If we can add to it, we should … as much as you can repeal, let’s get it done.”

The CBO has scored those three pieces of the proposal in the past and could deliver an analysis of the “skinny repeal” more speedily than of a more wide-ranging effort, GOP senators said. Still, Republicans will have to add additional Obamacare provisions to the bill to meet minimum savings requirements required under reconciliation, the budget mechanism that allows for a bare majority instead of 60-vote threshold.

Republicans are likely to cut the Prevention and Public Health Fund, for instance. The goal would be to increase the bill’s scope enough to meet Senate savings targets without losing political support, according to Republican sources. They may be able to do so because slashing the mandates means millions would drop insurance coverage — and the subsidies that come with it.

In the end, Senate leaders would want the House to either take up their bill or go to conference and hammer out a compromise that can pass both chambers.

“I can’t imagine at the end of the process that we haven’t agreed on something,” said Sen. Roy Blunt (R-Mo.). “And all we have to do is agree on something that keeps this going.”

But conservatives are wary of a House-Senate negotiation.

“I would [be in] favor if we have a skinny repeal, just sending it over to the House and seeing if they can pass it rather than going to conference,” Paul said. “Conference committee to me means Big Government Republicans are going to start sticking in those spending proposals.”

Running out of options to overhaul Obamacare, Senate Republicans ponder a ‘skinny’ repeal

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http://www.latimes.com/politics/la-na-pol-senate-healthcare-20170726-story.html

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nable to agree on a path forward to repealing the Affordable Care Act, SenateRepublicans are reluctantly coalescing around what may be the last idea standing: a dramatically scaled-down bill that would leave most of the 2010 law in place.

The so-called skinny repeal is still a work in progress, but one version being floated would repeal only three Obamacare provisions — a medical device tax and the mandates that individuals buy health insurance and that large employers offer it.

That’s far cry from the years-long GOP promise to gut the law, also known as Obamacare. But the face-saving strategy, which could come to a vote as soon as Thursday, would at least allow senators to say they acted on something.

It could also trigger a conference committee with House lawmakers to reconcile the Senate bill with the more sweeping House repeal legislation, giving lawmakers another shot at reaching agreement.

“I’ve got to think about moving things along to get to conference to hopefully get a good product,” said Sen. Charles E. Grassley (R-Iowa), who viewed the skinny alternative as a step toward something more comprehensive.

On Wednesday, GOP senators spent another frustrating and fruitless day debating and rejecting possible approaches.

After voting down their leaders’ most comprehensive overhaul plan a day earlier, Republicans rejected another long-standing GOP idea on Wednesday: to simply repeal most of Obamacare.

The amendment from Sen. Rand Paul (R-Ky.) mirrored a bill from conservatives that passed in 2015 but was vetoed by President Obama. Paul’s measure would have repealed the Affordable Care Act by 2020, theoretically providing time to devise a replacement law.

President Trump has at various times pushed the repeal-only idea, which was seen as the most straightforward approach amid disagreement within the party.

But Paul’s proposal failed to reach the 50 votes needed for passage, despite Republicans’ 52-seat Senate majority. Seven Republicans joined all Democrats in the 55-45 no vote.

That followed the late Tuesday rejection of GOP leaders’ Better Care Reconciliation Act, which had been bolstered with provisions to attract support from conservatives who want full repeal and centrists who worry about cuts to Medicaid.

Nine Republican senators voted against that idea.

“Clearly it has proven to be quite challenging to get 50 Republicans on board with one solution,” said Sen. John Thune (R-S.D.). “It’s been trying to move pieces around that would get everybody kind of comfortable and find a good landing spot. We just haven’t quite gotten there yet.”

Senators braced for an expected all-night session Thursday to consider about 100 amendments from Republicans and Democrats. None are likely to gain traction.

Even the skinny repeal is no sure thing, and leaders Wednesday were assessing what provisions could be cobbled together to win majority support.

A few GOP senators who have been hardest to satisfy voiced interest Wednesday in the scaled-down plan, including Sens. Rand Paul of Kentucky and Dean Heller of Nevada. Sens. Rob Portman of Ohio and Mike Lee of Utah also said they would review it.

For some, even a limited repeal would provide GOP senators an opportunity to pass a bill, declare victory and move on to other issues like tax reform.

Others hope to continue the fight if the legislation moves to a conference to be reconciled with the House bill.

Several Republican senators seemed open to that route, hoping to adjust the final bill in the negotiations to come. But whatever is agreed to in conference would still have to be approved by both the House and Senate.

Paul took the opposite stand. He said he could consider a limited repeal, but was worried that once negotiations with the House began, the legislation would be changed in ways he would not support.

It is highly possible that the House and Senate will not be able to resolve their differences, since they remain far apart on their approaches.

Rep. Mark Meadows (R-N.C.), chairman of the House Freedom Caucus and a key broker of the House-passed bill, said the skinny version had “zero” chance in that chamber.

Even so, some predict that House Republicans may be pressured to approve whatever skinny version ultimately passes the Senate, even if it is less ambitious than what Republicans once envisioned.

Meanwhile, many outside groups have voiced concerns about elements of the skinny plan, particularly if it repeals the individual mandate.

Though that mandate is unpopular with consumers, removing it could cause chaos in the insurance markets.

Without some kind of penalty, many healthy Americans would not get insurance until they were sick. That would push up health insurance costs, causing what people in the business call a death spiral.

The nonpartisan Congressional Budget Office estimated two years ago that repealing the mandates would increase the ranks of the uninsured by as many as 15 million, mostly people voluntarily dropping their coverage. It also estimated that premiums would increase by 20%.

On Wednesday, the skinny plan drew criticism from several leading healthcare groups, including the American Medical Assn., the nation’s largest physicians’ organization and the Blue Cross Blue Shield Assn., a health insurance trade group.

“A system that allows people to purchase coverage only when they need it drives up costs for everyone,” the insurance group warned in a statement.