Cloud of confusion hangs over health-care bill
By KELSEY SNELL AND AMY GOLDSTEIN | The Washington Post | Published: July 21, 2017
Senate Republican leaders' latest attempt to salvage support for a GOP health-care bill floundered Thursday as leaders struggled to explain to rank-and-file members what exactly they would be voting on next week.
Senators left town for the weekend under a cloud of confusion after Senate Majority Leader Mitch McConnell, R-Ky., reopened talks on a discarded plan to repeal and replace the Affordable Care Act under heavy pressure from President Donald Trump. The White House intervention sparked a flurry of meetings and activity, but the rush produced no new evidence that the bill can pass.
The situation was made worse Thursday by a new Congressional Budget Office estimate that the latest version of the GOP health plan would add 22 million people to the ranks of the uninsured in a decade - the same as a previous version of the bill. The news came one day after the CBO found that simply repealing the bill would leave 32 million additional people uninsured.
Senators had difficulty keeping up with the information in a rapidly shifting week when leaders floated plans to vote on both bills. McConnell started the week by promising to hold a vote on the repeal-and-replacement plan released last week. Facing fatal opposition to that plan, McConnell then announced that the Senate would vote on a repeal-only bill that passed the Senate in 2015 before being vetoed by President Barack Obama.
By week's end, leaders had returned to a repeal-and-replace strategy at Trump's behest.
On Thursday, most GOP senators could not say what legislation they expected to vote on next week, and skeptics appeared no closer to backing the new plan. Conservatives such as Sen. Rand Paul, R-Ky., who want to go further to pare back the ACA, and moderates such as Sens. Susan Collins, R-Maine, and Dean Heller, D-Nev., who worry about leaving millions without health-care coverage, remained undecided.
"It's still very vague and nebulous," Paul said. "It's hard to say you'll vote to proceed if you don't know what you're proceeding to."
Paul said that he is willing to move ahead with the bill if certain concessions are made, but the entire process left many GOP members frustrated and bewildered.
"In my experience of 37 years in public service I have never experienced a time when somebody stopped a leader on a motion to proceed," said Sen. Pat Roberts, R-Kan. "You can always vote against the bill or make an amendment or make a speech."
Sen. Bob Corker, R-Tenn., said he worries that Republican leaders have resorted to a haphazard process of writing a health-care bill that relies heavily on the wooing of individual senators to get the 50 votes necessary to pass the legislation.
"It's feeling a little bizarre like a bidding war right now," Corker said. "I fear that we're going to replace it with something that lacks coherency."
Despite the confusion, Senate Majority Whip John Cornyn, R-Texas, said the Senate is "very likely" to vote Tuesday to start debate on a health-care bill. But he did not provide further clarity on whether it would be trying to move to a pure repeal or the original repeal-and-replace bill McConnell effectively gave up on earlier this week.
When asked if senators would know whether they would be voting on repeal, repeal-and-replace or some other option Cornyn told reporters, "That's a luxury we don't have."
"Everybody can offer endless amendments," Cornyn said. "So if anybody's got a better idea they can offer an amendment and get a vote on it."
Behind closed doors, Senate leaders pleaded with rank-and-file members to vote next week to start formal debate on the ill-defined health-care measure, according to several GOP senators. Rather than promising members the chance to vote on a perfect replacement for the ACA, McConnell has offered to use the freewheeling amendment process as a chance to cobble together a consensus bill.
That decision represents the latest rapid strategic shift in a week that saw leaders abandon at least three repeal plans. Leaders had hoped members would be enticed by the chance to piece together a bill through consensus votes, but many skeptics were worried that the plan would fail to produce a final bill that can pass.
"I'm not convinced of anything at this point," Heller told reporters after a regularly scheduled GOP strategy lunch. "I'm not certain what leadership is trying to work."
Heller said he wanted to know what proposal would come up for a vote first if leaders got their way on an amendment free-for-all.
"I'd like to see a firm commitment," Heller said. "We didn't have a firm commitment as of lunch today."
All of the confusion had other skeptics like Collins planning for how to recover if the legislation fails next week. Asked whether she was laying the groundwork for a bipartisan approach of the current effort officially collapses, Collins replied: "Yes." But she didn't provide details.
Complicating matters further was the expected absence of Sen. John McCain, R-Ariz., who announced Wednesday that he has been diagnosed with brain cancer. Republicans control a slim 52-vote majority in the Senate. No Democrats are expected to vote for the bill, meaning Republicans can only lose two votes if they hope to start debate on the health-care bill - a margin that shrinks one without McCain.
Sen. John Hoeven, R-N.D., told reporters Wednesday that it would be significantly harder to pass a health-care bill without McCain.
"Obviously it's more challenging," Hoeven said.
Nearly lost amid the head-snapping changes was the latest CBO report, which found that the latest draft of the GOP replacement legislation would still drive up premiums and leave 22 million people uninsured. A single person buying a typical plan with inexpensive premiums could potentially confront a deductible of $13,000 a year after a decade.
Those deductibles would make insurance financially unattractive to many consumers, especially the poor. "Many people with low income would not purchase any plan even if it had very low premiums," CBO Director Keith Hall wrote in a letter conveying the estimates to Sen. Mike Enzi, R-Wyo., chairman of the Senate Budget Committee.
The estimate was based on a bill released last week that includes $70 billion to help customers buy insurance, $45 billion to treat opioid addiction and a new provision to allow people to use Health Savings Accounts to pay for premiums. Much of the new spending was financed by keeping a trio ACA taxes on high-income earners. GOP leaders chose to keep a 3.8 percent tax on investment income, a 0.9 percent Medicare payroll tax on individuals making $200,000 a year and couples earning $250,000 and a tax on insurers with highly paid executives.
The analysis found that a new form of tax credit for people who buy health plans on their own would be pegged to less generous insurance, covering about three-fifths of a patient's expected medical costs instead of about 70 percent with the current ACA subsidies.
Compared with earlier versions, it would give more money to states to help pay for insurance for high-cost patients and would preserve some Affordable Care Act taxes. It would still eliminate the law's requirement that most Americans carry health insurance, phase out the law's expansion of Medicaid and transform the rest of Medicaid funding.
This version would have a greater impact on lowering the federal deficit - a $420 billion reduction between next year and 2026, compared with $321 billion under the previous form of the bill, thanks in large part to the decision to keep the ACA taxes.
The CBO also says that the most recent version would cause a slightly slower erosion of health coverage - with 15 million fewer Americans predicted to be insured in 2018, compared with current law. That would be 2 million fewer losing insurance next year than under an earlier form of the legislation.
The bill that CBO scored does not include a controversial amendment put forward by Sen. Ted Cruz, R-Texas, which would allow insurers to sell minimal plans with limited benefits and lower premiums. Opponents say that it could destabilize the individual coverage market.
Still, many Republicans said they are eager to vote on repeal, even if they're not sure what the outcome will be.
"I think there is an assumption that we've made some progress," Roberts said. "We've got to get on the bill."
The Washington Post's Sean Sullivan contributed to this report.