Tierney Sneed

Tierney Sneed is a reporter for Talking Points Memo. She previously worked for U.S. News and World Report. She grew up in Florida and attended Georgetown University.

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The Senate Obamacare overhaul bill cuts a massive amount of federal funding of health coverage — a cut that will only increase in time – and replaces it with a comparatively minuscule pot of health care funding for the states. How that money will be used to paper over the massive spending cut will be left largely to the discretion of the Department of Health and Human Services, meaning the states will have to compete for the pool of available funds with no guarantees they’ll get the assistance they’ll need to make up for the shortfall.

“The [HHS] Secretary can do what he wants or she wants with the money,” Timothy Jost, a health law specialist at Washington and Lee University, told TPM.

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A top GOP senator did not rule out that possibility that Republicans would use the Department of Health and Human Services to score a controversial proposal in their revised Obamacare repeal legislation if the Congressional Budget Office was taking too look in its analysis.

“We will see,” Sen. John Thune (R-SD), the No. 3 Senate Republican,  when ask if Republicans will just depend on the HHS if CBO’s analysis isn’t ready in time. Majority Leader Mitch McConnell (R-KY) has said he’d like to take an initial, procedural vote on the bill next week.

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Senate Republicans released Thursday a revised version of its Obamacare repeal legislation, the Better Care Reconciliation Act. The tweaks to the bill come after the first version failed to get the 50 Republican votes needed to pass, and Majority Leader Mitch McConnell (R-KY) was forced to delay his plans to push the legislation through before the July 4 recess.

GOP leadership is hoping for a Congressional Budget Office score early next week, and an initial procedural vote to advance the legislation after that.

GOP senators weren’t expecting major changes to the initial draft, beyond the question of whether they’ll include a proposal from Sen. Ted Cruz (R-TX) to let insurers sell unregulated plans alongside Obamacare-compliant plans.

The language in the bill released Thursday allows for Obamacare’s tax credits for individual insurance to be used on “catastrophic plans” that cover at least three primary care visits.

A section of the revised bill, placed in brackets, sets aside $70 billion for insurers to subsidize high-risk individuals, presumably those would most likely to see their premiums rise under a proposal being pushed by Sen. Ted Cruz to let insurers sell unregulated plans. To qualify, insurers must sell a gold, silver and benchmark plan, under the new language. If they did, they could also sell policies that do not comply with Obamacare’s essential health benefits, its protections for pre-existing conditions and its ban on waiting periods.

The brackets mean that the policy continues to be worked upon as members react to it,” a senior senate policy staffer told reporters. “This is the first time that all members in our conference are taking a look at the language and they will likely have additional recommendations and thoughts for Senator Cruz and sponsors of the amendment to review.”

Health policy experts, the insurance industry and even some Republicans have warned that such a system would destabilize the market as healthy people flock to the stingy plans, leaving sick people in the comprehensives plans where they’d see their premiums skyrocket unless they received additional assistance.

Like the original draft, the new version repeals many of Obamacare’s taxes on the health care industry. But the legislation has been revised to keep the ACA taxes on net investments and a Medicare payroll tax for high earners. It also gets rids of a tax break the initial draft had for insurance executives.

Already, some key Republican swing votes were raising concerns that the new version would not to do enough to soften the bill’s massive cuts to Medicaid.

Like the initial draft, the process by which Medicaid expansion would be phased would still begin in 2021, when the enhanced match rate would start being reduced until it is drawn down to the traditional Medicaid match rate in 2024.  The larger program is, again, turned into a capped system in which the limits on the per-enrollee funding from the federal government rises more slowly than the program has typically grown, with a more draconian inflation metric imposed in 2025. Block grants are also available to the states, and the revised bill allows expansion states to include their expansion populations to be counted when tabulating the block grant.

A more generous formula for uncompensated care is also being used in the new version.

There is new language letting states apply for waivers for community-based care within their Medicaid programs. A provision to allow states to deal with public health emergencies outside of the caps has also been added.

The revised bill also includes $45 billion in funding for opioid programs, up from $2 billion in the initial draft.

The language was released as GOP senators huddled with Majority Leader Mitch McConnell to go over the changes. After the closed-door meeting, McConnell took to the Senate floor to defend the revised bill.

“After extensive consultations across the conference, numerous meetings with constituents and intensive conversation with members, our conference has updated last month’s Better Care discussion draft with additional provisions to make it stronger,” he said.

Read the legislation below:

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Proposals being pushed by Sen. Ted Cruz (R-TX), with the support of other conservative senators and outside groups, will be included in the revised Obamacare repeal language being unveiled Thursday, Senate aides confirmed to TPM.

An amendment allowing insurers to sell unregulated plans – which would be cheaper but could discriminate against people with pre-existing conditions – as long as they also sold an Obamacare-compliant policy, will be in the base text, as first reported by Axios. According to Axios, the amendment might still be changed or removed altogether, and the language in the draft bill will appear in brackets.

In the days leading up the revised bill’s unveiling, expected late Thursday morning, other Republicans were already throwing out suggestions to tweak Cruz’s idea to make it more workable and appealing to the conference.

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Thursday will be a deja vu moment on the Senate-side of the Capitol. Senate Republicans will gather in a private room off the Senate chamber to go over a freshly unveiled health care bill they hope they can pass to fulfill their years’ long promise of dismantling the Affordable Care Act.

Just like they did in June.

But, like the morning they went through this exercise a few weeks ago, deep disagreements remain among the conference over how to replace Obamacare and whether that effort should include a gutting of Medicaid. There’s been no sign yet that Majority Leader Mitch McConnell (R-KY) has hit the sweet spot. He needs to win 50 out of 52 Republican votes to pass the legislation. Yet he has previewed a quick turnaround time between unveiling his revisions to the Better Care Reconciliation Act and a vote on the bill, with a Congressional Budget Office score coming as early as Monday, and an initial procedural vote also next week.

Here are the five big unknowns going forward:

Did McConnell change enough to get rid of the old bill’s stench?

It was obvious that McConnell didn’t want to send members home for the July 4 recess without taking a vote on the legislation, and last week, while they were home, it became clear why. Very few Republicans aggressively promoted the legislation—many spent their recess in hiding—and those who did make public appearances distanced themselves from the effort.

Rank-and-file Republicans like Sen. Jerry Moran (R-KS) and John Hoeven (R-ND) came out against the old draft, and high-profile defectors like Sens. Shelley Moore Capito (R-WV) and Susan Collins (R-ME) defended their opposition.

Now, whether they can come back around will depend on if the revised bill at least looks different enough for them to justify supporting it. So far though, the sense is there hasn’t been a major overhaul—beyond Obamacare taxes for high-earners being preserved and extra funding for opioid programs.

“I don’t think there’s going to be that many dramatic changes,” Sen. Ron Johnson (R-WI) admitted to reporters Wednesday, after a Senate GOP lunch.

What the hell is going on with the Cruz amendment?

Perhaps the most substantive change to the legislation on the table is a proposal by Sen. Ted Cruz (R-TX) to let insurers sell unregulated plans as long as they offer an Obamacare-compliant plan as well. Cruz, however, could not tell reporters Wednesday when the CBO would be done scoring the provision, if it would be included with the legislation being unveiled Thursday or even when the text of his proposal will be made public.

Nonetheless, he indicated that he’d vote against advancing the bill, including on the first procedural vote, if it wasn’t part of the base legislation.

Other Republicans have raised concerns about Cruz’s idea, because it would likely to gut pre-existing protections many GOP lawmakers vowed to protect. The insurance industry agreed with their sentiments, in a statement bashing the Cruz proposal Wednesday.

Thus, other Republicans like Sen. Mike Rounds (R-SD) and Sen. Bill Cassidy (R-LA)  have been suggesting tweaks to Cruz’s proposal to make it more workable. Here again, the details are sparse. It’s unclear how far along they are in writing adjustments to Cruz’s amendment, whether those tweaks would solve the major policy problems, or how making those adjustments would fit in the aggressive timeline McConnell has laid out for passing the legislation.

Will moderates swallow big Medicaid cuts?

Enough Republicans opposed the draft bill’s deep Medicaid cuts to kill it. Yet, it’s expected that those provisions — which both scale back the ACA’s Medicaid expansion and gut the traditional program — will remain largely unchanged in the latest version.

Its passage, thus depends at least three of the following—Sens. Capito, Collins,  Dean Heller (R-NV), or Lisa Murkowski (R-AK)— flip-flopping on their previous requests that the cuts be softened.  Rounds suggested that tweaks to the Medicaid formulas could be made in the amendments process known as vote-a-rama that will occur on the Senate floor some time after next week’s expected procedural vote on the bill. There’s some skepticism, however, as to whether that would really result in substantive changes to the bill, since McConnell will still tightly control the process. (Hence, Cruz’s insistence that his proposal be included in the base text.)

“A fully amendable bill after the motion to proceed should give everyone a sense that they’ll have an opportunity to make whatever point they want to make,” Sen. Roy Blunt (R-MO), a member of the GOP leadership team, said.

Can they get the bill past the first hurdle?

We could know as soon as Tuesday whether the GOP repeal effort is doomed. McConnell has been insistent that a vote on the motion to proceed—which advances it procedurally to consideration, before a final vote—will come some time next week.

Some Republicans are arguing that, despite their or other GOP lawmakers’ reservations, they should at least vote for this initial step.

“I just can’t imagine not voting to proceed to a bill when you’ve got an open amendment process and you can offer any amendment you wish and you still have a vote at the end of the process,” Sen. Bob Corker (R-TN) said Tuesday.

Already one Republican, Sen. Rand Paul (R-KY), has said he’ll vote against it there, so it would only take two more GOP members to kill next week’s motion, perhaps if they see no point in taking politically tough votes during the vote-a-rama. The prospect of a failed motion to proceed was what McConnell was facing when he delayed a vote last time.

Is the timeline just too fast?

Which brings us to the next unknown: what happens if the votes aren’t there next week, but there’s a path to securing them in the future. McConnell has already delayed the August recess by an extra two weeks. Though he has said health care is still an agenda item for next week, there still is that extra time as a fallback. And by keeping some of Obamacare’s taxes on high-earners, McConnell has some money to work with to try to make things work. Will an extra two weeks be enough to settle on a version of the Cruz amendment that the broader GOP conference is willing to swallow? Or to make some adjustments to Medicaid provisions that expansion state senators can claim as their victory?

Or will McConnell decide that if he can’t draft a deal on health care now, a deal on health care is just not possible?

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The top insurance trade group on Wednesday came out against an amendment being pushed by some Senate Republicans in exchange for their support of the GOP Obamacare repeal bill.

America’s Health Insurance Plans (known as AHIP), said that the proposal by Sen. Ted Cruz (R-TX)—which would let insurers sell stingy, unregulated plans as long as they also offer at least one Obamacare-compliant plan—”would be infeasible and not solve the problems of an unlevel playing field” and would result in “unaffordable premiums for those with pre-existing conditions.”

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A group of 10 rank-and-file House Democrats released a white paper Wednesday with broad-stroke proposals to tweak the Affordable Care Act, as Senate Republicans enter their final crunch to pass an Obamacare repeal bill.

The proposals in the white paper range from codifying the insurer subsidies that President Trump has threatened to halt, to a Medicare buy-in for older consumers, to moving open enrollment to tax season, when Americans tend to be less cash-strapped than the current post-holidays enrollment deadline.

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Top Senate Republicans have indicated that it’s likely that the Affordable Care Act taxes on high-earners that the initial GOP repeal bill eliminated would be be put back in the latest draft expected this week.

“Well, that’s the current discussion, ” Sen. John Cornyn (R-TX), the No. 2 Senate Republican told reporters Tuesday afternoon, “that they will remain in there and the goal would be to provide more stability funds to help bring premiums down and more flexibility for the governors and legislators to deal with deductibles.”

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The tweaks that GOP leadership is making to its stalled Obamacare repeal legislation will not likely include a major rollback of its cuts to Medicaid, a top Republican told reporters Tuesday.

“What we had in the original bill has not changed with regard to Medicaid,” Sen. John Barrasso (R-WY) (pictured above), a member of the Senate GOP leadership team, said after a conference lunch where the revised bill was outlined in broad strokes. The text is set to be released on Thursday, with hopes for a new CBO score on Monday.

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Senate Majority Leader Mitch McConnell (R-KY) tamped down suggestions Tuesday that his announcement that the August congressional recess will be delayed for two weeks was a gambit to buy more time to pass an Obamacare repeal bill.

In a press conference after the delay announcement, McConnell said that the GOP was sticking with its timeline to try to pass the bill in the next two weeks or so.

“We’ll be on health care next week,” McConnell said, adding that the text of their revised bill will be released this Thursday, with hopes for a CBO score by early next week and a motion to proceed vote after that. He said the extra two weeks added to the work calendar in August were to process nominations that Republicans blame Democrats for delaying, as well as to deal with other legislative issues.

“We simply, as a result of all this obstructionism, don’t have enough time to address all of these issues between now and the originally anticipated August recess,” McConnell said.

He was later asked if the extra two weeks were a fallback for health care as well.

“We’re going to do health care next week,” McConnell insisted.

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