If Senate Republicans pass their Frankenstein monster of an Obamacare replacement plan this week, it’s because Majority Leader Mitch McConnell (R-KY) bent the dozen or so Republicans previously against it to his will, and not the other way around.
Few of the fundamentals of the repeal bill, the Better Care Reconciliation Act, have changed since McConnell delayed his initial plans for a vote last month. The major revisions Republicans did make, such as the preservation of some of the Affordable Care Act’s taxes, appeared to be optics-based, or even further alienated the senators wavering on the bill.
The last three weeks of feverish negotiations have been less about moving the ball, and more about moving the dirt around the ball to give it the appearance of moving.
At least 10 Republicans outlined fairly clearly over the last month what it would take for them to support the bill. If they do come around in time this week to pass it, for a vast majority of them it would not be the result of substantial change to the legislation, but rather enough of a fig leaf to claim they had won a concession.
Steep Cuts To Medicaid Have Been The Constant
The heart of the bill, a gutting of Medicaid, has remained intact through the entire process — from House Speaker Paul Ryan’s unveiling of his health care legislation in March, to the version that the Senate may vote on this week. Along the way, Republican leaders had plenty of opportunity to step back from these cuts, as criticisms mounted about using a bill ostensibly aimed at the Affordable Care Act.
“I have said all along that I felt that the Medicaid reforms should have been separate from the effort that we were undertaking with the ACA fixes,” Sen. Lisa Murkowksi (R-AK) told reporters last week.
Instead, GOP leaders doubled down. The latest version of the repeal does not scale back the draconian cuts to traditional Medicaid that grow even steeper in 2025. Nor did it give Medicaid expansion states a longer “glide path” in that program’s phaseout. Fifteen million fewer people would be enrolled in Medicaid by 2026, according to a CBO’s analysis released last week.
Senators concerned about the Medicaid cuts have been subjected to a smoke-and-mirrors operation, where they’ve been told that either the Medicaid cuts would be pushed off by a future Congress, or that the Trump administration would somehow be able to mitigate them, despite having significantly less funding available.
In at least one instance, the Medicaid double talk backfired, when conservative Sen. Ron Johnson (R-WI) erupted upon hearing that McConnell had played down to others the possibility the cuts would actually go into effect.
Meanwhile, an extra $70 billion in funding McConnell threw in the new bill that was being earmarked for more than one purpose made nary a dent in the coverage losses predicted by the CBO.
The Current Bill Splits The Baby On Insurer Regs
McConnell did make one major change to the most recent bill — in the form of an amendment Sen. Ted Cruz (R-TX) had been pushing — but it’s unclear whether the return on that risky investment has paid off.
The proposal allows insurer to sell non-Obamacare compliant plans and puts at risk protections for people with pre-existing conditions, which many Republicans said they would preserve.
McConnell won Cruz’s support with it. But the other conservative McConnell needed to woo, Sen. Mike Lee (R-UT), has balked on how the initial idea for the proposal had been watered down in the legislative text.
Lee’s issue is wonky, but one that makes or breaks his support. More largely, however, insurers have come out vehemently against the provision, which has not been scored by the Congressional Budget Office.
Now there’s “rumors” that a form of the amendment that Lee approves of will be included in the legislation that will be moved to the floor, but very little outside analysis suggests the proposal will work as promised. And beyond that, there’s also the chance it needs to be stripped from the bill due to the Senate rules constraining the complex legislative process Republicans are using.
A Secretive, Hasty Process Has Gotten Even More Slap Dash
Process arguments are usually besides the point. But McConnell’s decision to write most of the bill in secret and attempt a vote as soon it was unveiled clearly irked his members and that played a role in the initial delay.
Things haven’t gotten better on the process front.
A large part of the current replacement bill, the aforementioned Cruz amendment, remains unscored by the CBO. Republicans are instead relying on a sketchy, misleading Trump administration analysis to sell the proposal.
Other key provisions will likely have to be reworked after the Senate parliamentarian signaled that they would need Democratic votes to pass, due to Senate rules constraining the “reconciliation” process Republicans are using. If Republicans can tinker with their pseudo-individual mandate — a crucial measure to make the market function — to make it pass muster, that too will be unscored when it goes to the floor.
The CBO will also not have time to weigh in on whether any additional money thrown at the bill to win over Republicans wary of the Medicaid cuts will actually mitigate the coverage losses.
Speaking of additional money, the promises and assurances being made behind closed doors in these recent weeks are rubbing Republicans otherwise supportive of the legislation the wrong way.
“It’s starting to feel like a bazaar, $50 billion here, $100 billion there, and I feel like it’s losing coherency so I hope that somehow or another it can move in a different direction,” Sen. Bob Corker (R-TN) told reporters last week.
And then there’s the biggest question: will the replacement legislation be the actual final bill the Senate votes on, or will McConnell put forward a bill modeled after 2015 legislation that repealed Obamacare without a replacement, but with a two-year delay.
As of Monday evening, Republicans weren’t sure exactly which bill they’d be moving forward after Tuesday’s procedural vote.
“I don’t have a clue what we’re going to be voting on,” Sen. Ron Johnson (R-WI) told reporters Monday night. He opposed a vote on the replacement bill in July because he said he didn’t have enough information about it. He had not ruled voting on to move a bill forward Tuesday, even though he on Monday he did not what that bill was.