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Republican lawmakers in the Senate are days away from perhaps a final deadline on repealing and replacing the Affordable Care Act, a seminal promise from the party for more than seven years.
The Senate must pass the Graham-Cassidy healthcare bill by September 30 under budget reconciliation, the process that would allow it to pass with a simple majority.
Failure to pass the legislation using budget reconciliation would complicate prospects for the GOP to roll back the ACA, the landmark healthcare law known as Obamacare.
But despite pressure on Republican senators, two members have already said they will vote against the bill – and several others are on the fence, leaving its future in doubt.
“It’s very difficult for me to envision a scenario – scenario where I would end up voting for this bill,” Sen. Susan Collins of Maine said Sunday on CNN. “I have a number of serious reservations about it.”
Republicans are working with a difficult, crunched timeline. Here’s the gist:
- Monday: The first order of business is the Senate Finance Committee’s hearing on the bill at 2 p.m. ET. There will be six witnesses at the event. Tuesday: The Congressional Budget Office will issue a preliminary score for the bill. To qualify under budget reconciliation, the plan has to save the same as or more than the $119 billion projected to be cut from the federal deficit in the House’s American Health Care Act. The CBO said the score would not provide a detailed estimate of changes to insurance coverage or the stability of the insurance markets. Also on Tuesday: The Senate GOP will hold its weekly luncheon. It will give leaders an indication of where they stand on getting 50 votes for the bill. (Vice President Mike Pence would break any tie.) With only 52 Republicans in the Senate, there is little margin for error. Wednesday: The day will most likely bring the beginning of rulings from the Senate parliamentarian on the bill. All provisions of Graham-Cassidy are subject to the Byrd rule, which mandates all parts of a bill being considered under budget reconciliation must in some way affect the deficit. Anything that is ruled a violation of the Byrd rule would be stripped out. Also on Wednesday: The day Senate Majority Leader Mitch McConnell would start the voting process. Thursday: This is most likely the latest McConnell can introduce the bill to try to pass it before the deadline. If he does, it will trigger what is known as a vote-a-rama, which will allow senators of both parties to add as many amendments as possible. Saturday: The cutoff day to pass the bill.
Entering a hectic weak for healthcare, the outlook for the Graham-Cassidy bill does not look particularly promising for Republican leaders.
On Friday, Sen. John McCain of Arizona said he would vote against the bill because it was not introduced through “regular order.”
“I would consider supporting legislation similar to that offered by my friends Senators Graham and Cassidy were it the product of extensive hearings, debate, and amendment,” McCain said. “But that has not been the case. Instead, the specter of September 30 budget-reconciliation deadline has hung over this entire process.”
Additionally, Sen. Ted Cruz of Texas said at a festival on Sunday that he did not support the legislation as written.
“Right now, they don’t have my vote, and I don’t think they have Mike Lee’s either,” Cruz said, referring to the Republican Utah senator.
Sen. Rand Paul has been adamant about his opposition to the bill since the legislative text was introduced, calling it “Obamacare lite.” The Kentucky senator had been working on concessions that could get him to a yes, but his spokesman on Monday said Paul remained a “no” on the bill even after a new version was released Sunday.
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In the more moderate wing of the GOP, Collins said she was “leaning no” on the bill, while Sen. Lisa Murkowski of Alaska has not indicated her stance. Collins and Murkowski opposed every recent iteration of the Republican healthcare bills.
While the bill’s authors are tweaking the legislation to try to appeal to some of the wavering members, the political calculus is dicey. Moving the bill to the right to appease Paul, Cruz, and Lee risks cementing Collins’ and Murkowski’s opposition – and vice versa.
Working on some rewrites
The authors of Graham-Cassidy released a new version of the bill Sunday night.
The bill divides federal healthcare funding to the states using block grants – a lump sum of sorts paid up front to states – rather than the current percent match of actual spending.
The original bill used a formula that saw most states lose considerably, while a handful of mostly rural, Republican-controlled states gained funding. In the new version, the formula would be tweaked to benefit the states of members who have opposed or are wavering on the legislation.
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Maine, Kentucky, Arizona, and Alaska all get more federal funding than the original in the new version, according to a state-by-state breakdown released by the authors. But that does not account for the reduction in overall spending caused by the bill’s caps in Medicaid per capita – which would give states a set amount of money per Medicaid enrollee instead of fluctuating along with actual spending.
This means the bill would still slice significant federal healthcare funding over the next 10 years and eliminate the Medicaid expansion introduced by Obamacare altogether after that.
The bill also would loosen, and may even weaken further, protections for Americans with preexisting conditions – an issue highlighted by late-night host Jimmy Kimmel last week.
Under the new version, states can outline plans to bring down costs for healthcare in their state including loosening regulations created under Obamacare. That would allow states to loosen regulations mandating that insurers keep costs down for people with preexisting conditions.
Additionally, states could introduce two different risk pools in their plan – which would allow sick people to be placed in a separate, more expensive pool from one with healthier people.
Larry Levitt, a senior vice president at the Kaiser Family Foundation, a nonpartisan health-policy think tank, said the new version should end debate over whether sick people are protected under Graham-Cassidy.
“If there was any question about Graham-Cassidy’s removal of federal protections for pre-existing conditions, this new draft is quite clear,” Levitt tweeted Sunday. “The language in the revised Graham-Cassidy bill on insurance regulation is quite convoluted. It could take time to sort out. But…”