President Donald Trump summoned Republican senators to the White House on Tuesday afternoon as Senate Majority Leader Mitch McConnell announced he’s delaying a vote on his bill to repeal and replace Obamacare.
Squeezed between a group of moderate Republicans who think the bill hurts patients, and another group of conservatives who say the legislation doesn’t make enough changes to the Affordable Care Act, McConnell doesn’t have the 50 votes he needs to move ahead.
The road to passage for the Senate Republican health care bill got a steeper on Monday after the Congressional Budget Office determined the embattled draft legislation would cause 22 million people to lose health coverage by 2026 – barely a shift from the 23 million anticipated to lose insurance under House legislation passed this spring.
The Senate legislation would cause 15 million more people to lose coverage in 2018, and Medicaid enrollment would fall by 16 percent by 2026 under the proposal. In all, 49 million Americans would lack health coverage under the legislation in 2026, compared with 28 million under current law.
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“The increase would be disproportionately larger among older people with lower income—particularly people between 50 and 64 years old with income of less than 200 percent of the federal poverty level,” the report found.
The bill would save the government $321 billion over 10 years, mainly by cutting Medicaid spending by $772 billion or 26 percent over ten years, leading to 15 million fewer enrollees, the CBO estimated.
The disappointing numbers could complicate an already difficult task for McConnell, who needs 50 senators to vote for the widely criticized legislation to pass the upper chamber in a possible vote later this week.
But the CBO’s finding that the nation’s individual insurance markets would remain largely stable under the bill could help shore up support for the legislation.
The White House downplayed the report, claiming in a statement on Monday that CBO estimates about healthcare and insurance coverage have been historically inaccurate.
“This history of inaccuracy, as demonstrated by its flawed report on coverage, premiums, and predicted deficit arising out of Obamacare, reminds us that its analysis must not be trusted blindly,” a White House statement said....“As more and more people continue to lose coverage and face fewer healthcare choices, President Trump is committed to repealing and replacing Obamacare, which has failed the American people for far too long.”
In spite of the criticism, four conservative GOP senators have said they won’t support the legislation as written: Ted Cruz of Texas, Ron Johnson of Wisconsin, Mike Lee of Utah and Rand Paul of Kentucky. Among Republican moderates, Sen. Dean Heller of Nevada – facing a tough re-election race in 2018 – said he opposes the legislation, while Sens. Susan Collins of Maine, Lisa Murkowski of Alaska and Shelley Moore Capito of West Virginia are considered to be on the fence.
In an interview with CNN, Murkowski said she needs more time and more data before she decides whether to support the bill.
“I want to make sure that I understand what this really means for the people that I work for back home,” Murkowski said. “So I’m going to get the numbers and if I can’t get the numbers it’s really tough for me to make a fair and a balanced evaluation as to this bill.”
Senate leadership suggested there could be a vote as soon as Tuesday on a measure to put the bill into motion, but several members balked at the idea, saying they wanted more time.
Johnson said Monday that he saw “positive aspects” to the CBO report, though he hadn’t read the whole review. He said he’d like more time to study the report, calling it a mistake for McConnell to move too quickly.
Calling for a vote this week, he said, is “an artificial deadline. There’s really no reason for it. We should give members, our constituents, time to analyze this and collect genuine feedback.”
Sen. Susan Collins, R-Me., said she would vote against a motion to proceed, noting on Twitter that the Senate bill “doesn’t fix ACA problems for rural Maine.”
With 52 members in the Senate, Republicans can only lose two members and still pass the bill under budget reconciliation rules that prevent filibustering by Democrats. Vice President Mike Pence would cast the tiebreaker in the event of a 50-50 tie.
In order to win more support, McConnell’s team is expected to amend the legislation significantly this week in a furious effort to meet President Donald Trump’s goal of bringing the measure to a floor vote before the July 4 congressional recess.
But adding legislative sweeteners to woo conservative and moderate senators alike will prove tricky, since changes to appease one side will likely alienate the other.
The legislation, known as the Better Care Reconciliation Act, was revealed by the Congressional Budget Office to be very similar to its counterpart, the American Health Care Act, which narrowly passed the House of Representatives last month. The CBO estimated the AHCA would cause 23 million people to lose health coverage by 2026.
Like the AHCA, the Senate legislation would cut subsidies that help purchase marketplace insurance, phase out the Medicaid expansion and slash funding for Medicaid by $772 billion over ten years, compared to $834 billion in the House legislation.
The Senate legislation also would abolish most of the taxes that funded the Affordable Care Act’s coverage expansion. Most of the lost tax revenue would fund tax breaks that disproportionately benefit wealthy individuals.
The bill also would make coverage more expensive for older people and those with pre-existing medical conditions.
Ten patient and provider advocacy groups, including the American Heart Association, the March of Dimes and United Way Worldwide, sent letters to all 50 state governors asking them to contact their senators and state representatives about the bill’s “potentially devastating consequences.”
The American Medical Association gave their thumbs-down to the legislation on Monday, as well, saying the bill violates a basic tenet of medicine: “first, do no harm.” The draft legislation “violates that standard on many levels” said Dr. James L. Madara, CEO of the American Medical Association, in a Monday letter to Senate leaders.
Advocates for low-income, disabled and elderly Floridians sounded alarm Monday about the impact of the bill on the state’s most vulnerable residents – elderly and disabled Medicaid enrollees.
About 100,000 Floridians with severe disabilities depend on Medicaid for home and community based services, such as occupational therapy and physical rehabilitation, in order to avoid institutionalization, said Miriam Harmatz, a senior health attorney with Florida Legal Services, a non-profit legal aid group.
Home and community based services for disabled Americans with Medicaid is an optional benefit under the program and approved through a federal waiver. Because those services are optional, Harmatz said, states are more likely to cut those services before they reduce mandatory care, such as hospitalization and nursing home care.
“That’s the funding stream that states have access to that allows people who are very disabled and need additional services ... to stay at home,” Harmatz said, noting that many of the people who camped out in McConnell’s office last week were protesting cuts to those programs.
The CBO estimates that average premiums for benchmark plans for single people would be about 20 percent higher next year “mainly because the penalty for not having insurance would be eliminated, inducing fewer comparatively healthy people to sign up.”
That problem was partially addressed on Monday, however, when the legislation was amended to include, beginning in 2019, a six-month waiting period for coverage to begin for people who went without insurance for 63 days or more in the previous year. Enrollees would not have to pay their premiums during the waiting period.
Insurers lobbied for the change because the bill, as originally written, would have repealed the ACA’s mandatory coverage requirement without imposing a new penalty for people who let their coverage lapse. That would have allowed people to game the system by waiting until they were sick to enroll in coverage.
Republicans will also find solace in the CBO determination that individual insurance markets in most areas of the country would be stable under the legislation in 2020 and beyond mainly due to tax credits to help purchase coverage.
“That stability in most areas would occur even though the premium tax credits would be smaller in most cases than under current law and subsidies to reduce cost sharing, would be eliminated starting in 2020,” the report found.
The Senate bill would give states more power to waive key provisions of the law through the ACA’s “Section 1332” waiver provision. These include allowing states to weaken or eliminate the ACA’s “essential health benefits” requirement.
The CBO said some areas of the country, particularly sparsely populated rural areas, may not have any insurers and could face “market disruptions” if states enact significant changes under the waiver provision.
“These markets are potentially destabilized if there’s any kind of miscalculation,” CBO staff said during a briefing with reporters on Monday. But those problems would likely be temporary.
“We anticipate the flexibility offered by waivers would allow a state to correct those situations,” CBO staff said.
Daniel Chang of the Miami Herald contributed to this report from Miami.