Af­ter early drama, un­cer­tainty in bill

McCain ap­pear­ance, Pence tiebreak re­vive de­bate; late vote fails

The Denver Post - - FRONT PAGE - By Amy Gold­stein and Paige Winf ield Cun­ning­ham

WASH­ING­TON» On a squeaker of a vote, the Se­nate be­gan an ex­tra­or­di­nary de­bate Tues­day over pro­found philo­soph­i­cal and prac­ti­cal changes to the na­tion’s health­care sys­tem — with­out know­ing what the leg­is­la­tion would be.

Law­mak­ers started with a bill that the House passed this past spring to dis­man­tle much of the Af­ford­able Care Act, of­ten called Oba­macare. It is a mea­sure that many Se­nate Repub­li­cans have never liked and was brought up Tues­day solely to kick things off.

The ac­tion then im­me­di­ately piv­oted to an­other bill that also has no re­al­is­tic chance of suc­cess: a reprise of a plan to kill off big parts of the ACA with­out any re­place­ments. It was adopted two years ago by both cham­bers of Congress and was ve­toed by Pres­i­dent Barack Obama.

By night­time, the Se­nate had taken its first vote, re­ject­ing one per­mu­ta­tion of its main anti-ACA leg­is­la­tion and mov­ing on to an­other amend­ment.

And so be­gan a leg­isla­tive kalei­do­scope sched­uled to last for 20 hours of de­bate in com­ing days,

fol­lowed by yet more amend­ments and votes. Even as it started turn­ing, a new last re­sort al­ready was in sight — a skimpy plan be­ing dubbed “skinny re­peal” that could stand mainly as a way to keep the health-care is­sue alive at least through the sum­mer.

Af­ter seven years of GOP prom­ises to tear down the ACA, this is the un­pre­dictable course on which Se­nate Ma­jor­ity Leader Mitch McCon­nell, R-Ky., now finds him­self. De­spite his rep­u­ta­tion as a mas­ter tac­ti­cian, McCon­nell has been un­able in re­cent weeks to wran­gle his frac­tious cau­cus into a co­he­sive health-care vot­ing bloc.

Based on what sen­a­tors were say­ing Tues­day, here are some of the plans and amend­ments likely to come up for de­bate or a vote — po­ten­tially in dif­fer­ent com­bi­na­tions — in com­ing days:

Bet­ter Care Rec­on­cil­i­a­tion Act

This is the main leg­is­la­tion that the Se­nate’s Repub­li­can lead­ers have de­vised to get rid of much of the ACA and sub­sti­tute a more con­ser­va­tive set of health poli­cies. Orig­i­nally in­tro­duced June 26, it is now in its third ver­sion and is al­most cer­tain to be al­tered fur­ther.

The Bet­ter Care Rec­on­cil­i­a­tion Act would elim­i­nate cen­tral fea­tures of the cur­rent law, which a Demo­cratic Congress pushed through in 2010. It would end fed­eral penal­ties for peo­ple who vi­o­late the cur­rent law’s re­quire­ment that most Amer­i­cans carry health in­sur­ance and for em­ploy­ers with 50 or more work­ers who do not of­fer health ben­e­fits. It also would cut the sub­si­dies that help more than 8 in 10 con­sumers af­ford the monthly pre­mi­ums of health plans they buy through the ACA’s in­sur­ance mar­ket­places.

The plan would sub­sti­tute a dif­fer­ent form of tax cred­its, smaller for many peo­ple be­cause they would be tied to skimpier health plans. Un­like the ACA sub­si­dies, how­ever, the pro­posed cred­its would be avail­able to peo­ple be­low the fed­eral poverty line.

Af­ter two years, the bill also would abol­ish a dif­fer­ent ACA sub­sidy that now helps about 7 mil­lion lower-in­come con­sumers af­ford their cov­er­age de­ductibles and other out-of­pocket ex­penses.

Med­i­caid, the joint statefed­eral pro­gram of health in­sur­ance for the poor, would be trans­formed in two ways. The ex­pan­sion of the pro­gram un­der­taken by 31 states un­der the ACA would be phased out in a few years. More fun­da­men­tally, its half-cen­tury tra­di­tion as an en­ti­tle­ment - with the gov­ern­ment pay­ing a cer­tain share of the costs in each state, no mat­ter how high - would be re­placed by per-per­son caps or block-grant fund­ing. Ei­ther is pre­dicted to squeeze the fed­eral pay­ments as time goes on.

Late last week, the Se­nate’s par­lia­men­tar­ian threw a wrin­kle into Se­nate Repub­li­can lead­ers’ plans, con­clud­ing that cer­tain as­pects of the leg­is­la­tion could not be con­sid­ered through a bud­get process that would al­low it to pass by a sim­ple ma­jor­ity of votes. These in­clude fea­tures, pop­u­lar among con­ser­va­tives, that would deny fund­ing for Planned Par­ent­hood and health plans that al­low cov­er­age for abor­tions.

Fifty-seven sen­a­tors op­posed the BCRA. Fortythree, in­clud­ing U.S. Sen. Cory Gard­ner of Colorado, sup­ported it, por­tend­ing a dif­fi­cult road ahead for the GOP roll­back ef­fort.

Cruz amend­ment

Sen. Ted Cruz, R-Texas, has been tout­ing a change to the Bet­ter Care Rec­on­cil­i­a­tion Act that would en­able in­sur­ers largely to ig­nore ACA rules re­quir­ing health plans sold to in­di­vid­u­als and small busi­nesses to cover spe­cific ben­e­fits. In­sur­ers could jet­ti­son ma­ter­nity care, men­tal-health treat­ment and other ben­e­fits as long as they sell as least one health plan that in­cludes them.

Cruz has said that this change would lead to lower in­sur­ance rates for healthy peo­ple, and an­a­lysts sug­gest that it would do so. How­ever, an­a­lysts also ex­pect that peo­ple who need more med­i­cal care would face sig­nif­i­cantly higher prices, be­cause health plans’ “risk pools” would be splin­tered be­tween health­ier and sicker groups.

This amend­ment has been un­pop­u­lar with GOP cen­trists in the Se­nate.

Port­man amend­ment

Sen. Rob Port­man, ROhio, comes from a state that ex­panded Med­i­caid and has been out­spo­ken in pre­dict­ing that the BCRA even­tu­ally would starve the pro­gram and leave more peo­ple unin­sured.

He now has come up with a vari­a­tion of an idea that the Trump ad­min­is­tra­tion’s top health of­fi­cials have been heav­ily lob­by­ing ex­pan­sion states to em­brace: Tax cred­its that peo­ple on Med­i­caid would re­ceive to buy pri­vate health plans. Many of the gover­nors tar­geted have said no to the ad­min­is­tra­tion’s of­fer, pre­dict­ing that such low-in­come res­i­dents still could not af­ford the pri­vate cov­er­age.

Port­man’s amend­ment would pro­vide $100 bil­lion to help those peo­ple cover their de­ductibles and other ex­penses if they switched out of Med­i­caid, and it would let states set up such ar­range­ments with­out need­ing spe­cial fed­eral ap­proval.

Re­peal-only bill

The only re­peal bill ever to pass Congress would have left in­tact some pop­u­lar ACA in­sur­ance rules, such as let­ting young adults stay on their par­ents’ health plans to age 26. But the 2015 mea­sure would have ended the law’s cov­er­age man­dates, its sub­si­dies for most peo­ple buy­ing health plans through the ACA mar­ket­places and the law’s Med­i­caid ex­pan­sion.

Sen. Rand Paul, R-Ky., has cham­pi­oned this kind of re­peal with­out sub­sti­tutes, view­ing it as a purer ver­sion of ACA re­peal and thus more ac­cept­able. He pro­vided a cru­cial vote to start the health-care de­bate Tues­day af­ter be­ing promised that the cham­ber would vote on this mea­sure. Other Repub­li­cans, how­ever, aban­doned the idea of a re­peal-only bill months ago, be­liev­ing it would up­end cov­er­age for mil­lions of peo­ple and dev­as­tate in­sur­ance mar­kets.

A “skinny re­peal”

Adding a new phrase to the crowded lex­i­con of health-care pol­icy, “skinny re­peal” would abol­ish just three parts of the ACA: The in­di­vid­ual and em­ployer in­sur­ance re­quire­ments, plus a tax on med­i­cal-de­vice man­u­fac­tur­ers.

A close vari­ant of this sur­faced two years ago in the House, and con­gres­sional bud­get an­a­lysts es­ti­mated at the time that 15 mil­lion fewer Amer­i­cans would have in­sur­ance cov­er­age “most years” as a re­sult.

C-Span2

U.S. Sen. John McCain, R-Ariz., speaks on the floor of the Se­nate on Capi­tol Hill in Wash­ing­ton on Tues­day. McCain re­turned to Congress for the first time since be­ing di­ag­nosed with brain cancer.

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