The Atlanta Journal-Constitution
Senate health bill may alienate conservatives
Changes to House measure target moderates.
WASHINGTON — Senate Republicans are closing in on a bill to repeal President Barack Obama’s signature health care law, diverging from the House on pre-existing medical conditions and maintaining federal subsidies that proponents see as essential to stabilizing insurance markets around the country.
The changes appear largely designed to appeal to Republican senators who hail from states where the Affordable Care Act is popular and who were critical of the House bill, which would eliminate insurance for millions of Americans covered under the current law, according to the Congressional Budget Office.
But the revisions may well alienate the Senate’s most conservative members, who are eager to rein in the growth of Medicaid and are unlikely to support a bill that does not roll back large components of the current law. Even with more moderate Republicans on board, party leaders would have a very narrow margin for passage on the Senate floor.
“I think it’s fair to say that the House bill was something necessary to move it to the Senate, but I don’t think that anyone expected that the House bill would define what the Senate did,” said Sen. Bill Cassidy, R-La., who called the chances for approval in the Senate “better than 50-50.”
Republicans appeared to be on a swift march to repeal the Affordable Care Act when the new Congress convened this year, even as Democrats were determined to preserve the law. The deterioration of health insurance markets in some states has added to the pressure on lawmakers to take at least some action in the next few months.
Senate Republicans, meeting daily behind closed doors, are coalescing around a proposal that would provide money for “cost-sharing reduction” payments, which insurance companies receive under the Affordable Care Act so they can reduce deductibles and other outof-pocket costs for low-income consumers.
House Republicans filed a lawsuit in 2014 asserting that the Obama administration was paying the subsidies illegally because Congress had never appropriated money for them, and a U.S. District Court agreed last year. The conflict puts the Senate on a potential collision course with both the House and the White House, which has sent decidedly mixed messages on what it wants to do with the subsidies, causing insurers to panic.
Sen. Rob Portman, R-Ohio, said Congress needed to provide money for the cost-sharing subsidies.
“The administration has delayed a decision from month to month,” he said. “We need to deal with it as soon as possible to provide some stability in the market.”
Portman noted that Anthem, one of the nation’s largest insurers, cited uncertainty about the payments when it announced this week that it would pull out of Ohio’s health insurance exchange next year, leaving consumers in some counties without options.
Insurers, doctors, hospitals and the U.S. Chamber of Commerce have been urging President Donald Trump to ensure payment of the subsidies. But Trump has threatened to withhold them as a way to force Democrats to negotiate with him on a replacement for the 2010 health care law.
Seven million people benefit from the cost-sharing subsidies, which cost the federal government $7 billion a year. The House bill did not include money for them, and Trump’s mixed signals have spooked insurers.
The Trump administration has also indicated that it will loosen enforcement of the requirement for people to have coverage or pay a penalty.
Harvard Pilgrim Health Care cited uncertainty about that requirement, the individual mandate, as one reason it proposed rate increases that would raise the average monthly premium in the Maine marketplace by 39.7 percent, to $655 in 2018 from $469 this year.
Republican senators are still waiting for more details, and an evaluation by the Congressional Budget Office of the Senate measure’s cost and impact, before agreeing to support any legislation that would fulfill years of Republican promises to unravel the health care law.
Democrats, who have been left out of a process that requires only 51 votes, are almost certain to be critical of the measure, which goes well beyond changes needed to solve problems roiling insurance markets in many states.
“We have not been included in any of these discussions,” said Sen. Patty Murray, D-Wash. “Clearly, they want to move forward and get this monkey off their backs, but it is a monkey, and they’re going to pay the price if they go that direction.”
Senate Majority Leader Mitch McConnell has a narrow pathway to victory. Only two of the chamber’s 52 Republicans can abandon him, with Vice President Mike Pence then breaking a tie vote.
Sen. Rand Paul, R-Ky., is widely expected to oppose any bill that does not at least mirror the House measure in rolling back federal insurance standards, and Sen. Mike Lee, R-Utah, is likely to have similar concerns. Sen. Patrick J. Toomey, R-Pa., is looking for deeper cuts in the projected growth of Medicaid, which could turn off other Republican senators, including some from states, like Portman’s, that expanded the program.
Under the bill passed by the House last month, states could opt out of certain provisions of the Affordable Care Act, including one that requires insurers to provide a minimum set of health benefits and another that prohibits them from charging higher premiums based on a person’s health status.
Senate Republicans generally agree that it is desirable to give states more flexibility, allowing them to obtain waivers from the federal definition of “essential health benefits,” such as maternity care, emergency services and mental health coverage.
But many Republicans are reluctant to dilute the protections for people with pre-existing conditions.
Asked if insurers should be allowed to charge higher rates to people with such conditions, Cassidy said, “The simple answer is no.”
Congress has roughly 30 legislative days to pass a bill before the August recess. If the Senate is able to pass one by then — a goal of McConnell — it is unclear whether its provisions could be melded with those in the House version.
On a trip to Ohio on Wednesday, Trump again pressed for a bill.
“Obamacare is in a total death spiral, and the problems will only get worse if Congress fails to act,” he said. “It’s only obstruction from the Democrats. The Democrats are destroying health care in this country.”
With no prospect of votes from Democrats, he said, “it’s all going to be Republicans or bust.”