Anyone following the debate over the “repeal and replace” of the Affordable Care Act knows the 13 Republican senators writing the bill are meeting behind closed doors.
While Senate Majority Leader Mitch McConnell (R-Ky.) continues to push for a vote before the July 4 Senate recess, Washington’s favorite parlor game has become guessing what is, or will be, in the Senate bill.
Spoiler: No one knows what the final Senate bill will look like — not even those writing it.
“It’s an iterative process,” Senate Majority Whip John Cornyn (R-Texas) told Politico, adding that senators in the room are sending options to the Congressional Budget Office to try to figure out in general how much they would cost. Those conversations between senators and the CBO — common for lawmakers working on major, complex pieces of legislation — sometimes prompt members to press through and other times to change course.
Although specifics, to the extent there are any, have largely stayed secret, some of the policies under consideration have slipped out, and pressure points of the debate are fairly clear. Anything can happen, but here’s what we know so far:
1. Medicaid expansion
The Republicans are determined to roll back the expansion of Medicaid under the Affordable Care Act. The question is, how to do it. The ACA called for an expansion of the Medicaid program for those with low incomes to everyone who earns less than 133 percent of poverty (around $16,000 a year for an individual), with the federal government footing much of the bill. The Supreme Court ruled in 2012 that the expansion was optional for states, but 31 have done so, providing new coverage to an estimated 14 million people.
The Republican bill passed by the House on May 4 would phase out the federal funding for those made eligible by the ACA over two years, beginning in 2020. But Republican moderates in the Senate want a much slower end to the additional federal aid. Several have suggested that they could accept a seven-year phaseout.
Keeping the federal expansion money flowing that long, however, would cut into the bill’s budget savings. That matters: In order to protect the Senate’s ability to pass the bill under budget rules that require only a simple majority rather than 60 votes, the bill’s savings must at least match those of the House version. Any extra money spent on Medicaid expansion would have to be cut elsewhere.
2. Medicaid caps
A related issue is whether and at what level to cap federal Medicaid spending. Medicaid currently covers more than 70 million low-income people. Medicaid covers half of all birthsand half of the nation’s bill for long-term care, including nursing home stays. Right now, the federal government matches whatever states spend at least 50-50, and provides more matching funds for less wealthy states.
The House bill would, for the first time, cap the amount the federal government provides to states for their Medicaid programs. The CBO estimated that the caps would put more of the financial burden for the program on states, who would respond by a combination of cutting payments to health care providers like doctors and hospitals, eliminating benefits for patients and restricting eligibility.
The Medicaid cap may or may not be included in the Senate bill, depending on whom you ask. However, sources with direct knowledge of the negotiations say the real sticking point is not whether or not to impose a cap — they want to do that. The hurdles: how to be fair to states that get less federal money and how fast the caps should rise.
Again, if the Senate proposal is more generous than the House’s version, it will be harder to meet the bill’s required budget targets.
3. Restrictions on abortion coverage and Planned Parenthood
The senators are actively considering two measures that would limit funding for abortions, though it is not clear if either would be allowed to remain in the bill according to the Senate’s rules. The Senate Parliamentarian, who must review the bill after the senators complete it but before it comes to the floor, will decide.
The House-passed bill would ban the use of federal tax credits to purchase private coverage that includes abortion as a benefit. This is a key demand for a large portion of the Republican base. But the Senate version of the bill must abide by strict rules that limit its content to provisions that directly impact the federal budget. In the past, abortion language in budget bills has been ruled out of order.
4. Reading between the lines
A related issue is whether House language to temporarily bar Planned Parenthood from participating in the Medicaid program will be allowed in the Senate.
While the Parliamentarian allowed identical language defunding Planned Parenthood to remain in a similar budget bill in 2015, it was not clear at the time that Planned Parenthood would have been the only provider affected by the language. Planned Parenthood backers say they will argue to the Parliamentarian that the budget impact of the language is “merely incidental” to the policy aim and therefore should not be allowed in the Senate bill.
5. Insurance market reforms
Senators are also struggling with provisions of the House-passed bill that would allow states to waive certain insurance requirements in the Affordable Care Act, including those laying out “essential” benefits that policies must cover, and those banning insurers from charging sicker people higher premiums. That language, as well as an amendment seeking to ensure more funding to help people with preexisting conditions, was instrumental in gaining enough votes for the bill to pass the House.
Eliminating insurance regulations imposed by the ACA are a top priority for conservatives. “Conservatives would like to clear the books of Obamacare’s most costly regulations and free the states to regulate their markets how they wish,” wrote Sen. Mike Lee (R-Utah), who is one of the 13 senators negotiating the details of the bill, in an op-ed in May.
However, budget experts suggest that none of the insurance market provisions is likely to clear the Parliamentarian hurdle as being primarily budget-related.
–Julie Rovner, Kaiser Health News
Richard Smith says
So why are you printing/publishing “leaked” news that hasn’t been voted on, finalized or passed in Congress? You are just as guilty as the leaker. Shame on you!
Mr. Smith, there is no such thing as “leaking” the public’s business. We are informing of of what your representatives are doing with your tax dollars, but don’t want you to know, hopefully before they vote on it so we are all, members of congress included, better informed as to what should and should not be voted for. You’re free to prefer to remain in the dark. FlaglerLive is not for everyone, though you seem to spend more time here than most.
If you really want to read between the lines,the middle class and a lot of the higher paid lower class wage earners will pay for it all. Sad but true. Let the wealthy pay for this healthcare
Traveling Rep says
Secretive??? Trivia question: Who said, during a presser “we’ve got to pass it to see what’s in it” regarding the ACA (the make you really, really poor act).
Well, right now we’re getting more information than we did last time, ala “we have to pass the bill to find out what’s in it”, a quote which Nancy Pelosi will rue to her dying day.
What are the other Members of Congress working on? I believe we all know the answer to that one.
Personally. . . “I” want to know what is in ALL the bills being considered in Congress BEFORE the vote happens! How am I able to have any input at all, otherwise????
I’m so frustrated with this two party system! Neither parties don’t go far enough to help it’s constituents. And what frustrates me even more are that the people who vote Republican can’t even see past their noses and support this reaping of riches and take a ways of what they like to brand “Entitlements” despite the harm it does to themselves and others. It’s our tax dollars. What ever happened to ” For the People By the People”.
Please Mr President just let all the lovers of Obamacare watch it die once and for all. They just keep crying and crying over their precious Obamacare which is literally falling apart and almost dead already. Good grief people get a grip already.
ObamaCare was publically discussed, over 150 GOP Amendments where added the final Bill, before itvwas made Law. No tax breaks for the wealthy were included. The law had problems that could have and should have been addressed but, the GOP decided that they would declare war on it rather than fix it. 64 votes to Repeal and the constant negative discussion of it’s future caused insurance companies to drop out of the market place. What we end up with is a new law which will cause another economic collapse by making health unaffordable while creating massive tax benefits for the rich. When will the GOP develop a brain and a heart?
Benjamin Bartlett says
* Guilty of “leaking” news, which we are entitled to read.
* Guilty of publishing “news entitlements.”
* Guilty of being informative.. the nerve, with verve!
Sad? Sad is a bunch of wackos still thinking they can keep dying Obsmacare which was the Democrats invention. Now that is sad and crazy both. The nerve of most Americans not wanting the profram to begin with, but the democrats and Obama forced it anyway. Now let it die like it should have to begin with. It never should have been passed. Now that is sad!
Common Sense says
Republicans had eight years to come up with something better. They didn’t.
Trump said he had a plan that would be “wonderful”, would cover everyone and cost less. He didn’t.
Republicans criticized Pelosi for saying it had to pass, etc. But now they are working in secret and don’t even want others in their party to read it.
The AHCA was discussed and amended and published for everyone to see before it was passed.
Even Trump had to admit that their first version was “mean”.
This bill, if passed, will leave millions of Americans uninsured and will give tax cuts to the rich.
This is the worst president and administration this country has ever had.