WASHINGTON D.C., — The closely guarded Senate health care bill written entirely behind closed doors finally became public Thursday in a do-or-die moment for the Republican Party’s winding efforts to repeal Obamacare.
The unveiling of the 142-page bill marks the first time that the majority of senators get a look at the plan to overhaul America’s health care system. With Majority Leader Mitch McConnell pressing ahead for a vote next week, senators now only have a handful of days to decide whether to support or vote against the bill.
Four conservative Republican senators — Rand Paul, Ted Cruz, Ron Johnson and Mike Lee — said they opposed the current version. And key votes such as Sens. Dean Heller and Susan Collins have also withheld support.
“As currently drafted, this bill draft does not do nearly enough to lower premiums,” Cruz said in a statement obtained by CNN. “That should be the central issue for Republicans — repealing Obamacare and making health care more affordable. Because of this, I cannot support it as currently drafted, and I do not believe it has the votes to pass the Senate.
The bill would repeal Obamacare’s individual mandate, drastically cut back federal support of Medicaid, and eliminate Obamacare’s taxes on the wealthy, insurers and others.
President Donald Trump praised the bill Thursday — though he acknowledged that changes were likely coming.
“It’s going to be very good,” Trump said at the White House. “A little negotiation but it’s going to be very good.”
With the exception of some key changes — notably keeping Obamacare’s subsidies to help people pay for individual coverage — the bill is similar to the version of the House measure that passed last month which Trump has since called “mean” despite having a Rose Garden celebration with House Republicans.
Democrats blasted the bill, using Trump’s “mean” judgment of the House bill.
“The Senate bill needed heart, the way this bill cuts health care is heartless,” said Minority Leader Chuck Schumer. “This is a nasty bill and they’re trying to cover it up with little things here and there.”
“Tomorrow in Connecticut when I hold another hearing – and we may have another afterward – many of my colleagues may wonder why. They may well be scared of having that kind of hearing where they have to listen to the voices and see the faces of people who will suffer under this bill. They certainly have been too scared to have that kind of hearing in the United States Senate. I will hear from the people this bill will hurt. I will hear from people whose lives will be put at risk as a result of this heartless, cruel, costly measure. I will be inspired to fight even harder, and I will fight as long and hard as possible to assure this bill never becomes law,” Connecticut Sen. Richard Blumenthal said.
Rep. John B. Larson said, “It is no surprise that the Senate kept their bill hidden for so long. The bill still devastates Medicaid, still endangers the Medicare trust fund, and will still cause millions of Americans to become uninsured. However, I am most concerned about the impact of the Senate’s bill on those living with pre-existing conditions and the ability of the middle class to get affordable, comprehensive care. This bill remains a tax proposal, not a bill to help the people of Connecticut. The bill is Robin Hood in reverse; it provides tax cuts to the wealthy on the backs of the middle class. When we passed the ACA, we had an open and transparent process with public hearings, committee debates, and the adoption of amendments from both sides of the aisle. The Senate is rushing this bill to the floor without any input from the American public. In the words of President Trump, for so many Americans especially the working poor and the middle class, this bill is mean.”
Congressman Jim Himes said, “Today, after weeks of negotiations behind closed doors by a small group of Republican Senators, Majority Leader Mitch McConnell unveiled the Senate Republican plan to repeal and replace the Affordable Care Act. Much like the House-passed bill that I opposed, the Senate plan rolls back health care coverage for the neediest Americans in order to pay for enormous tax breaks for the wealthiest. It forever shrinks Medicaid, includes grave cuts to Planned Parenthood, enables higher deductibles, and lets states opt out of requiring that insurance companies cover essential health benefits, like hospital visits, maternity care, and mental health services.
Can McConnell get the votes?
McConnell’s decision to keep the details tightly under wraps until Thursday was intentional and aimed at winning over his colleagues out of the public spotlight, but the secretive process has infuriated Democrats — and aggravated plenty of Republicans, too.
McConnell has very little room for error — he can only lose two Republican votes and still pass the bill — and GOP senators were not jumping to support it.
“Currently, for a variety of reasons, we are not ready to vote for this bill, but we are open to negotiation,” Paul, Cruz, Johnson and Lee said in a joint statement. “There are provisions in this draft that represent an improvement to our current health care system, but it does not appear this draft as written will accomplish the most important promise that we made to Americans: to repeal Obamacare and lower their health care costs.”
Sen. Orrin Hatch, R-Utah, told CNN that it would be “very difficult” for lawmakers to digest the bill in time for a vote next week.
Heller — who will have a tough re-election in Nevada next year — expressed “serious concerns” about the bill’s impact on constituents who depend on Medicaid.
“If the bill is good for Nevada, I’ll vote for it and if it’s not — I won’t,” Heller.
Still, others were more upbeat.
GOP Sen. John McCain, who has been openly critical of the lack of transparency in the crafting of the bill, said the proposal was better than Obamacare in “100 ways.”
Four senators openly opposed the legislation in its current state but said they were open to negotiations, while another four senators expressed varying levels of concern with the draft.
Republicans can only afford to lose two of their 52 senators for the bill to pass.
Most Republicans are still reviewing the text, but here is what many have said so far:
Opposes in current form but open to negotiations: 4
Sen. Rand Paul (Kentucky) — “The current bill does not repeal Obamacare. It does not keep our promises to the American people. I will oppose it coming to the floor in its current form, but I remain open to negotiations.” (Paper statement on 6/22)
Sen. Ted Cruz (Texas) — “The current draft does not solve the problem, but I’ve been working to an agreement. People are unhappy with premiums because it has caused premiums to skyrocket. The current draft made this morning doesn’t do what we need to fix that problem.” (To reporters on 6/22)
Sen. Ron Johnson (Wisconsin) and Sen. Mike Lee (Utah) — “Currently, for a variety of reasons, we are not ready to vote for this bill, but we are open to negotiation and obtaining more information before it is brought to the floor. There are provisions in this draft that represent an improvement to our current health care system, but it does not appear this draft as written will accomplish the most important promise that we made to Americans: to repeal Obamacare and lower their health care costs.” (Joint paper statement on 6/22)
Still reviewing but has concerns: 4
Sen. Susan Collins (Maine) — “Senator Collins will carefully review the text of the Senate health care bill this week and into the weekend. She has a number of concerns and will be particularly interested in examining the forthcoming CBO analysis on the impact on insurance coverage, the effect on insurance premiums, and the changes in the Medicaid program.” (Paper statement on 6/22)
“It makes no sense to single out Planned Parenthood from all the Medicaid providers…there’s already a ban against using federal funds for abortion so there’s absolutely no need for that.” (To reporters on 6/22)
Sen. Dean Heller (Nevada) — “At first glance, I have serious concerns about the bill’s impact on the Nevadans who depend on Medicaid. I will read it, share it with Governor Sandoval, and continue to listen to Nevadans to determine the bill’s impact on our state…As I have consistently stated, if the bill is good for Nevada, I’ll vote for it and if it’s not — I won’t.” (Paper statement on 6/22)
Sen. Mike Rounds (South Dakota) — Rounds said there were some “good parts” to the bill but there needs to be more work done on group markets. (To reporters on 6/22)
Sen. Rob Portman (Ohio) — “There are some promising changes to reduce premiums in the individual insurance market, but I continue to have real concerns about the Medicaid policies in this bill, especially those that impact drug treatment at a time when Ohio is facing an opioid epidemic. I look forward to examining this new proposal carefully and reviewing the analysis by the Congressional Budget Office when it is available. If the final legislation is good for Ohio, I will support it. If not, I will oppose it. As this process moves forward, I will continue to work to protect Ohio’s interests and ensure that our health care system works better for all Ohioans.” (Paper statement on 6/22)
Still reviewing: 11
Sen. Lisa Murkowski (Alaska) — “I’m going to look at it first. That’s really what I gotta do.” (To CNN on 6/22)
Sen. John McCain (Arizona) — McCain told reporters he generally praised the bill, and said it was better than Obamacare in “100 ways.” He said he still needed more time to study bill before deciding if he’d support it, and in particular wanted feedback from the Arizona governor on Medicaid provisions. He said he wasn’t happy with this process but thought one week was enough time to review the bill for a vote. (To reporters on 6/22)
Sen. Cory Gardner (Colorado) — Told reporters “we need to learn more and get the information and numbers behind it….That’s not a no. It’s not a yes. We have to look at the numbers.” (To reporters on 6/22)
Sen. Bob Corker (Tennessee) — The Senate Foreign Relations Chairman said he’s not “happy or unhappy” about the bill and that he’s going to go back and read it. (To reporters on 6/22)
Sen. Lindsey Graham (South Carolina) — “I came away more positive than I thought I’d be. … This is a proposal from the leadership that is expected to change. This bill is not take it or leave it. It is a starting point where we can look at the bill from our state perspectives.” (To reporters on 6/22)
Sen. Pat Toomey (Pennsylvania) — “A lot to digest … a work in progress. Very good start.” (To reporters on 6/22)
Sen. Tim Scott (South Carolina) — “I’m close to yes.” (To reporters on 6/22)
Sen. Thom Tillis (North Carolina) — “As I’ve said repeatedly, any replacement plan must be a net improvement over Obamacare, and I look forward to carefully reviewing the draft legislation over the next several days.” (Paper statement on 6/22)
Sen. Marco Rubio (Florida) — “Senator Rubio will decide how to vote on health care on the basis of how it impacts Florida. He has already spoken to Governor Scott, Senate President Negron and Speaker Corcoran about the first draft of this proposal…He will continue to reach out for input and suggested changes from Florida providers, insurers and patient advocate groups.” (Paper statement on 6/22)
Sen. John Kennedy (Louisiana) — “I think it’s a good start, but I want to read it. I’ll spend a lot of time on it this weekend.” (To reporters off cam on 6/22)
Sen. James Lankford (Oklahoma) — “Put me down as a solid undecided.” (CNN’s “The Lead with Jake Tapper” on 6/22)
Likely yes: 2
Sen. Orrin Hatch (Utah) — “While this discussion draft will help move the effort forward, I will continue to review this proposal and work with my colleagues to provide better care for all Americans.” (Paper statement on 6/22)
Senate Majority Whip John Cornyn (Texas) — “The time to close the book on Obamacare is now. Our plan will help deliver access to better care at a price the American people can actually afford.” (Paper statement on 6/22)
What will CBO say?
The bill will have to undergo parliamentary scrutiny to ensure that it meets the strict requirements on what can or can’t be included in a bill under the budget reconciliation process.
One report that will inform Senate Republicans as they decide whether to support the bill will be a score from the non-partisan Congressional Budget Office, which says it will release it early next week.
The CBO analysis will shed light on how much money the bill would cost and how many people would be covered. Senate Republicans hope to see better headlines from this CBO report than the one that the House GOP legislation received. CBO said the House bill would result in 23 million fewer people insured in 2026 than under Obamacare.
Pre-existing conditions, Medicaid and other key issues
Pre-existing conditions: The Senate bill would require insurers to cover those with pre-existing conditions and ban them from basing premiums on consumers’ health history.
But it would allow states to waive the federal mandate on what insurers must cover, known as the essential health benefits. This would allow insurers to offer less comprehensive policies, so those with pre-existing conditions may not have all of their treatments covered.
Last-minute House concessions to conservatives would have allowed states to opt out of several protections for those with pre-existing conditions.
Medicaid: This has been one of the central sticking points in the debate. The bill would continue the enhanced Medicaid expansion funding from Obamacare until 2021 and then phase it out over three years. This is a concession to moderates, who weren’t pleased that the House version would end the enhanced support for new enrollees in 2020.
However, conservatives also get some of what they want when it comes to overhauling the entire Medicaid program. The Senate bill would keep the House plan to send a fixed amount of money to states each year based on enrollment or as a lump sum block grant. But it would shrink the program even more over time by pegging the annual growth rate of those funds to standard inflation, rather than the more generous medical inflation, starting in 2025. This would likely force states to cut enrollment, benefits or provider payments.
Premiums subsidies: The Senate bill would also largely maintain Obamacare’s premium subsidies structure, but tighten the eligibility criteria starting in 2020. Fewer middle class folks would get help because only those earning up to 350% of the poverty level would qualify, rather than the 400% threshold contained in Obamacare. But it would also open up the subsidies to enrollees below the poverty level so those living in states that didn’t expand Medicaid could get some assistance.
Senators opted to keep Obamacare’s subsidies to prevent the funds from being used for abortions. The House bill called for creating tax credits based largely on age, but adding abortion restrictions to these credits could have run afoul of Senate rules governing the bill. Still, the similarities to Obamacare will likely infuriate conservatives such as Kentucky Senator Rand Paul, who decried the House version as “Obamacare Lite.”
Planned Parenthood: As in the House bill, it would defund Planned Parenthood for one year.
Cost-sharing subsides: The bill would also aim to shore up the existing Obamacare market by allocating funds for the cost-sharing subsidies until 2019. This will placate insurers, who were distraught by Trump’s refusal to commit to continue making these payments, leading many carriers to hike rates or drop out of the exchanges for 2018.