Senate sets up health votes for chaotic Obamacare debate

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(Bloomberg) --Senate Republicans have embarked on an unpredictable and potentially chaotic floor debate aimed at repealing Obamacare amid significant doubts that they can muster 50 votes to pass any kind of health bill.

GOP leaders will hold votes on a slew of different health bills to see how close they can get to passing something. The debate -- which will be punctuated with skirmishes over obscure rules and parliamentary challenges -- will culminate in an all-night “vote-a-rama” later this week that could feature dozens, or even hundreds, of amendment votes.

At the end of it, Republican leaders hope to be able to pass a health bill, even if it’s just a slimmed-down Obamacare repeal that only scraps a handful of the law’s most unpopular provisions.

“Everything’s on the table,” said Senator John Cornyn of Texas, the No. 2 Republican leader. “It’s whatever we can get out of the Senate and get to a conference” with the House to reach a compromise.

Senate Republicans voted Tuesday to begin the debate by the slimmest of margins, requiring Vice President Mike Pence to cast a tie-breaking vote. A number of Republicans warned, even as they voted yes, that they weren’t ready to back any of the current proposals.

‘Shell of a bill’

Even Republican Senator John McCain, who made a dramatic return from his home in Arizona, where he was recently diagnosed with brain cancer, to vote to begin the debate, made clear that he’s not on board with any final product.

“I will not vote for the bill as it is today. It’s a shell of a bill right now. We all know that,” he said in a fiery floor speech. “I know many of you will have to see the bill changed substantially for you to support it.”

Two Republicans -- Susan Collins of Maine and Lisa Murkowski of Alaska -- voted against beginning debate, and opposition from a single additional senator would block passage of any health bill.

Murkowski “really let the Republicans, and our country, down yesterday. Too bad!” President Donald Trump tweeted Wednesday morning.

Senate Democrats vowed to try to stop the measure, and called on outside groups to help pressure wary Republicans.

“We are going to fight and fight and fight until this bill is dead,” Senate Minority Leader Chuck Schumer said at a rally outside the Capitol shortly after the vote to proceed with the debate.

Republicans are utilizing a fast-track Senate procedure known as reconciliation that can avoid a filibuster by Democrats and allow a final measure to pass with as few as 50 votes. But there are strict rules that mean a host of provisions Republicans are seeking could be successfully challenged by Democrats, based on early guidance from the Senate parliamentarian.

Here are some of the proposals that the Senate is considering this week:

Repeal and replace

The most fleshed-out Republican plan, drafted in a secretive process by McConnell, would repeal much of the Affordable Care Act and replace it with a program of more limited subsidies to help people buy insurance. It would also roll back Obamacare’s expansion of the Medicaid program to include more low-income people.

The Senate defeated a modified version of that bill 43-57 in a Tuesday night vote. The measure needed 60 votes to advance because it contained several provisions that, according to the Senate parliamentarian, violated the rules of the fast-track procedure being used by Republicans, including one that would defund Planned Parenthood for a year.

The Congressional Budget Office has estimated that an earlier version of the McConnell plan would result in large numbers of additional uninsured Americans -- 22 million more by 2026. While premiums for some people would decline, patients would pay more out of pocket.

The earlier version would reduce the deficit by $420 billion over 10 years, the CBO said. But the CBO estimate didn’t include two key amendments, one offered by Senator Ted Cruz of Texas and another from Rob Portman, an Ohio Republican.

Cruz amendment

Cruz has proposed letting insurers sell low-cost insurance plans with few regulations or coverage requirements, so long as they also sell more robust plans. Health insurers have said it would upend the insurance market by encouraging healthy people to buy the cheaper plans while sick or higher-risk people are forced into increasingly expensive policies.

But the CBO hasn’t issued an estimate of his proposal yet, so it didn’t qualify under the fast-track procedure. That means it needed 60 votes to pass the Senate.

Avalere Health found that the Cruz amendment would lower premiums by 77 percent in 2022 on average for healthy people who don’t need much care. For people who need more comprehensive plans similar to ones currently offered under Obamacare, premiums would be 39 percent higher by 2022.

While it hasn’t been scored by the CBO, an analysis by the Trump administration’s Health and Human Services Department estimated that between 14.8 million and 16.1 million people would be enrolled in the individual market under the Cruz plan. Health insurers have criticized it, calling the Cruz plan “unworkable in any form.”

The ‘wraparound’ amendment

The proposal from Portman is designed to help low-income people who lose their Medicaid coverage and move to private insurance plans. It would add $100 billion to the Better Care Reconciliation Act’s stability fund, and also give states more flexibility to use federal dollars to help poor people who buy the private plans with out-of-pocket costs.

The proposal hasn’t been evaluated by the CBO. But it’s been pushed by Seema Verma, Trump’s head of the Centers for Medicare and Medicaid Services. Several GOP senators, including Alaska’s Dan Sullivan and Louisiana’s Bill Cassidy, have commented favorably on it as well.

It may be under-funded compared to Medicaid coverage through current law, however. The Urban Institute estimated that it could cost $33.6 billion in just 2022 to help low-income people with out-of-pocket costs. Adding other types of aid they’d need brings the total to between $76 billion and $100 billion for that year alone, researchers at the Urban Institute found.

Full repeal

Opponents of plans to replace Obamacare with a more limited set of subsidies have called for a full repeal of the law, with a two-year delay so that lawmakers could craft a new program. Yet doing so could throw Obamacare’s markets into chaos in the meantime, according to the CBO, and if lawmakers couldn’t come up with a new plan, there would be large coverage losses.

That amendment is expected to receive a vote on Wednesday and isn’t expected to pass.

The plan is similar to one Republicans passed in 2015, and that was vetoed by then-President Barack Obama. Trump has indicated that he would sign it.

Full repeal without a replacement would lead to 32 million more uninsured than under Obamacare, the CBO has estimated. Premiums would also go up by about 25 percent next year -- and by more afterwards -- since only the sickest would buy coverage. In addition, about half of the population would end up living in areas where no insurer would offer plans in the nongroup market by 2020, a number that increases to about three-fourths of Americans by 2026, CBO found.

Full repeal would reduce the deficit by $473 billion over 10 years, according to the CBO.

‘Skinny’ repeal

A “skinny repeal” strategy is shaping up as the fallback option for Republican leaders if the party can’t agree on a broader repeal. It would likely end Obamacare’s requirement that all people have insurance coverage or pay a fine, known as the individual mandate, and also repeal a requirement that companies give coverage to their full-time workers. A repeal of the tax on medical devices could be included too.

Repealing Obamacare’s mandate that all Americans have insurance coverage would raise the number of uninsured people by about 15 million by 2026, according to a December CBO estimate. That would slash federal spending by $416 billion a decade, because fewer people would use U.S. subsidies to buy coverage or sign up for Medicaid, according to the CBO.

The policy would also raise health insurance premiums by about 20 percent, since fewer young, healthy people would buy coverage. Insurers have voiced concern that eliminating the mandate will have a negative effect on the stability of the insurance market and could cause them to raise rates.

Other options that have been floated include the Collins-Cassidy plan, named for senators Collins and Cassidy. It would let each state decide whether to keep Obamacare. Cassidy and South Carolina Senator Lindsey Graham have also floated a plan that would take hundreds of billions in federal funding from Obamacare’s taxes and send it to states to run their own health insurance markets as they choose.

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