confirmed that the Senate is planning to hold its floor vote on ACA repeal and Medicaid restructuring next week, before adjourning for the July 4 recess week, without the benefit of any public process. Although many Republican Senators continue to decry the process, their objections are obviously just for show since it would only take three of them to stop the bill in its tracks until a more deliberative process was put in place. Yet they have continued to play the part of helpless bystanders rather than exercise the power that they actually have. As a result, a bill that has the potential to affect one-sixth of the U.S. economy, and the lives of tens of millions of people, will hit the Senate floor next week with only a minimal opportunity to assess the potential damage it would do. More details could emerge as soon as Thursday, with a Congressional Budget Office score to follow shortly thereafter, but under Majority Leader McConnell’s strategy, there will be very little time between the score release and the vote, with essentially no procedural opportunity to make improvements.
In addition to answering key policy questions, the release of Senate bill language – when it finally happens – will show how Sen. McConnell has decided to approach the political divides in the chamber: specifically, whether he will follow the House path and appease his most conservative members while daring the “moderates” to vote “no;” or whether he will, instead, take to heart Trump’s recent criticism of the “mean” House bill and actually try to produce something slightly less bad while daring the right in both the Senate, and ultimately the House, to vote “no.”
Here’s a guide to what to look for whenever the Senate language finally emerges:
Despite all the talk about starting over, expect the Senate bill to largely track the House-passed bill with a bit of window dressing thrown in that Senators will point to in an attempt to save face after having verbally panned the House plan in the hours and days after its passage.
More than anything else, the House version of the AHCA is at its core about drastically cutting Medicaid to pay for huge tax cuts for the wealthy and for big drug and insurance corporations. There is every indication that the Senate version will follow suit. The debate in the Senate has largely taken for granted the conversion of the Medicaid program from one that guarantees matching funds to states to one that caps federal payments and shifts costs onto the states, providers and beneficiaries. Although a bipartisan group of governors has recently raised concern about this, there has been virtually no dissension within the Senate GOP. Instead, the Senate debate has revolved around the rate of growth of those federal payments and the fate of the Medicaid expansion the ACA authorized.
A number of GOP senators have indicated that they want a growth rate no worse than the House bill’s while also killing off the Medicaid expansion more slowly – e.g., a seven-year phaseout of the enhanced federal matching funds that make the expansion possible, rather than an abrupt cutoff in 2020. Some other senators have been arguing for a more miserly federal growth rate than that in the House bill.
Look for the Senate proposal to offer a slower phaseout of the expansion than the House version’s, coupled with a stingier growth in the cap after a few years of tracking the House formula. This will be portrayed as a “compromise,” but it would in actuality be a surrender on the part of those who have been arguing that the Senate should do better than the House with respect to Medicaid. Ultimately, the coverage expansion will still be totally eliminated, while funding for older adults, people with disabilities and children is squeezed even harder as it phases out. The wild card here is that the biggest losers would be the states that did not expand Medicaid in the first place. They would get nothing at all from a slower phaseout while receiving fewer federal matching funds for their existing Medicaid beneficiary population. It is not beyond the realm of possibility that this deal could cause some Senators who are normally reliable votes for McConnell to reconsider their support.
The cap growth rate and expansion phaseout are the “marquee” Medicaid issues, but a host of details will also be important, such as what the base year will be for setting the cap, what – if any – adjustments are made over time and how caps are calculated for different populations.
Lipstick on the Pig:
While the basic Medicaid deal in the Senate is shaping up to be at least as bad as the House bill’s, rumor has it that the Senate may exclude some children with special health care needs from the funding cap. In addition, there has been discussion about including a separate fund to address opioid addiction. The notion is that these modifications would allow the GOP senators to (try to) claim that they are being less “mean.”
With regard to the private non-group market, expect the Senate to rely on a tax-credit structure that adjusts for income and age but is still far less generous than that currently in effect under the ACA. We also expect that states would still be allowed to waive rules related to the benefit package but that plans would not be allowed to charge higher premiums to people with pre-existing conditions. People with expensive medical needs would still be harmed, though, because without a comprehensive benefit package, a lot of the cost of care could be shifted back to individuals.
Access to Reproductive Health Services
Look for the defunding of Planned Parenthood to remain in the bill. Although senators Collins and Murkowski are likely to offer an amendment to strike that provision, such an amendment will probably fall short on a 50-50 tie. The question then will be whether either or both these senators will vote “no” on final passage, thereafter. In addition to defunding Planned Parenthood, the House bill tries to prohibit tax credits from being used for any insurance plan that covers abortion services. This provision will probably be struck as a violation of Senate budget reconciliation rules, but the Senate is looking for an alternative route to achieve the same objective.
To the extent that there is a need for additional revenue to meet the House deficit reduction target, the Senate will likely delay the effective date of some of the tax cuts that are in the bill. In the alternative, they could temporarily suspend some of the tax cuts with an expectation that they could do a full repeal later.
Where Are the Votes?
Despite the haste, or perhaps because of it, it remains unclear whether the votes to achieve passage are there in the Senate. At the risk of oversimplifying: to get the requisite 50 votes for the Senate bill to pass – with a tie-breaking “yes” vote assist from Vice-President Pence – McConnell will have to keep at least four of the six Senators who comprise the most conservative and most moderate flanks of his caucus – Cruz, Lee, Paul on the right and Collins, Murkowski and Capito in the middle. He will also have to keep Sen. Heller of Nevada on board – the most endangered member of the GOP caucus up for reelection in 2018, being from a state that has benefited greatly from the ACA. Sen. McConnell has to do those things while also preventing any other defections from senators whose states stand to lose big time in numerous ways under this bill (which is really kind of all of them).
With thanks to Quynh Chi Nguyen, policy analyst, for her assistance.