If Senate Republicans pass their Obamacare repeal bill, they’ll have no one but themselves to blame for the consequences.
The contents of their bill, expected to be unveiled Thursday, have been a closely guarded secret, held so tightly to the chest, that members of the so-called health care working group say they didn’t know what was in it before its rollout.
Yet it’s hard to imagine that it will result in anything else but coverage losses by the millions. Senate Republicans are widely expected to follow the model of the House health care overhaul legislation, which the Congressional Budget Office said would result in 23 million fewer people with health coverage by 2026, a $834 billion cut to Medicaid and an insurance landscape where in some places, people with pre-existing conditions will be priced out of affording insurance.
GOP senators are making tweaks around those edges, but the major takeaway remains: nearly a trillion dollars in federal funding for health care is being slashed, mostly by raiding Medicaid, in order to pay for a tax cut that benefits high earners and the industry.
The House legislation, the American Health Care Act, was opposed vehemently by hospital groups, patient advocates, women’s health activists, senior citizens organizations and medical associations. Senate Republicans too swore the House bill wasn’t good enough, and vowed to improve its framework. But in the two and a had months since, they have shunned the press and the public from assessing their proposals. They have blown off meetings with patient groups. Besides a few meetings with insurance reps, they’ve kept the industry in the dark on key questions, including the fate of insurer subsidies that, if halted, could disrupt the individual market.
That insularity has meant they’ll have few allies to help lawmakers improve upon the nasty reputation the House bill has already gained among the public. More importantly, with no buy-in from the industry or patient advocates, they’ll have no one to help shoulder the fallout from the mammoth coverage losses.
And after shutting off the outside world from weighing in on their negotiations, the Senate GOP’s rank-and-file will have only a week—assuming Majority Mitch McConnell (R-KY) sticks with the plan for a vote next Thursday or Friday—to consult with external analysts to determine how their bill will affect their states.
The turnaround is “too quick,” Sen. Susan Collins (R-ME) admitted to TPM Tuesday. “It’s going to be hard to get it thoroughly vetted,” she said.
There has been plenty of griping about the opaque process, but no Republican senators seem so perturbed that he or she would withhold their vote until the proceedings became more transparent.
“You probably have used your chit,” Sen. Bill Cassidy (R-LA) said, when asked Tuesday why he and two other members weren’t making that sort of threat to McConnell. “Maybe you want three Republicans to say, ‘We won’t vote for it unless we have this in the bill.’ If that makes sense.”
And on a policy level too, Republicans have been hesitant to publicly draw any red lines. Their wobbliness, particularly from Republicans from expansion states or towards the center of the ideological spectrum, have already put them at disadvantage in the negotiations. And claims that they were “concerned” about their most vulnerable constituents won’t give them much cover if and when they eventually vote for a bill that kneecaps the safety net program.
Asked by Axios about the further cuts the Senate GOP is reportedly considering, compared to the House bill, to impose on traditional Medicaid, Sen. Shelley Moore Capito (R-WV) called it a “problem” but wouldn’t say she’d vote against a bill that included it.
“I don’t look favorably on it, that’s for sure,” she said.
Senate Republicans have been explicit that their top priority is a bill that can get 50 votes. There has been little offered by GOP lawmakers in terms of a broader health care philosophy or policy goal they’re trying to solve, beyond basic talking points about “lowering premiums” and “stabilizing the markets.”
Ask rank-and-file Republicans what mechanisms in their bill deliver on these promises, and they often come up short.
“I can’t show to my constituents back home anything concrete because we don’t have anything,” Sen. Lisa Murkowksi (R-AK) told Vox last week. “We’ve been talking about ideas. But for instance, if you are going to eliminate Medicaid expansion or even if you’re going to wind down Medicaid expansion, that’s not increasing access.”
At its heart, the repeal efforts appears to be, in fact, a trojan horse for Republicans to gut Medicaid, after President Trump ran explicitly on preserving the program.
They have been warned by state officials—Democratic and Republican—that the elimination of the ACA Medicaid expansion and the caps placed on traditional Medicaid funding could have devastating consequences that affect everything from substance abuse programs to nursing homes to special needs schools. Even the insurance industry has cautioned that the gutting Medicaid will have a negative impact on the private insurance market.
Yet it appears that the Senate is heading towards an even more draconian form of the capped system than the House bill, while the debate over the expansion has focused in on when it will be phased out, not whether it should be eliminated.
The potential impact of the cuts, particularly in many of the rural states from which Republican senators hail, is grave. Rural hospitals already operating on shoe-string budgets will be hit particularly hard. Funding to fight the opioid addition would wither. It will fall to states to make the hard choices of whether to cut benefits, further squeeze providers, or raid other parts of their budgets to make up for the shortfall.
Asked to take a stand on various repeal bill proposals, Republicans senators have in recent days been able to punt by saying they wanted to wait to see a bill. With the text, they won’t be able to dodge much longer, and the reckoning stands to be more dramatic if the legislation becomes law.
“If at the end of the day, this ends up easing some of the pain that’s out there right now relative to health care, I think people will look favorably upon that,” Sen. Bob Corker (R-TN) said, according to Politico. “If it ends up making things worse, I think they will look upon it very much like the ’09 bill passage did [among Democrats].”