If Senate Republicans are going to pass a bill to partially repeal and replace Obamacare, it appears they’ll need everyone but libertarian Rand Paul and moderate Susan Collins to do it.
On Thursday morning, a new version of the Senate GOP health care bill was released. Changes included keeping some of Obamacare’s tax hikes to provide more money in order to assuage the concerns of moderates, while also providing regulatory relief to win over the votes of conservatives. But within hours Collins and Paul announced that they would oppose opening up debate on the bill. Many Republicans remain undecided, and with all Democrats opposed the loss of just one more Republican would block a vote in the Senate.
The provisions to win over conservatives include a version of Ted Cruz’s Consumer Freedom Amendment and allowing individuals to pay for insurance premiums with pre-tax dollars through Health Savings Accounts. The Cruz amendment would allow an insurer that sells an Obamacare-compliant plan in a state to sell plans that don’t adhere to almost all of Obamacare’s costly regulations. As TWS previously reported:
Cruz’s plan could solve the central problem of Obamacare, which is that the program provides coverage to people with pre-existing conditions on the individual market by forcing a tiny slice of the population—relatively healthy middle-class families and individuals who don’t have employer-sponsored health insurance—to pay thousands of dollars more each year for health insurance.
Cruz’s plan would allow these middle-class families on the individual market without high healthcare costs to purchase cheaper plans, while also protecting those with pre-existing conditions in the Obamacare-compliant plans. In effect, it would turn the Obamacare-compliant plans into high-risk plans, but insurance could remain affordable to those with pre-existing conditions because the premiums are capped at a percentage of income for those earning 350 percent of the poverty line or less (that is, a modified adjusted gross income of $85,000 or less for a family of four).
This would cause the cost of the subsidies to skyrocket for those in the Obamacare-compliant plans, but conservative senators say having taxpayers transparently pick up the tab makes more sense than forcing the small number of people who lack an employer-sponsored plan to pay for those with pre-existing conditions.
“You are very transparently taking care of those people, and we’re all taking care of them,” Ron Johnson said, “as opposed to forcing that cost on the very small slice of the population.”
Cruz announced on Thursday that “if this is the bill, I will support it.” And Wisconsin’s Ron Johnson also sounded likely to vote for the current bill, although he says he is officially undecided until he reads the entire bill.
What’s unclear is whether or not Cruz’s conservative ally Mike Lee of Utah will vote for the bill. Mike Lee trashed the original Senate GOP health care bill, but said he would vote for it if it allowed states or individuals to opt out of Obamacare. Lee believed that the original version of Cruz’s amendment accomplished the latter goal, but he’s unsure if the current bill does that. “The new Senate health care bill is substantially different from the version released last month, and it is unclear to me whether it has improved,” Mike Lee said in a statement. “I will need time to study the new version and speak with experts about whether it does enough to lower health insurance premiums for middle class families.”
The complicated and technical change from the original Cruz amendment to the one introduced Thursday is that, as Philip Klein reported, “the bill does not waive the requirement that each state have a single risk pool, meaning the exempted plans and the plans that have to meet Obamacare requirements will be part of the same risk pool.” Supporters of one risk pool believe that would stabilize the market, but it’s unclear how this plan would work. “Actuaries I have spoken with do not understand how a single pool would work in this universe,” tweeted New York Times health care reporter Margot Sanger-Katz. “[S]o then you can see why not being able to waive the regulation would be a big deal,” replied Lee spokesman Conn Carroll.
The votes of a handful of moderate senators who are concerned primarily about Medicaid reform—including Ohio’s Rob Portman, West Virginia’s Shelly Moore Capito, and Alaska’s Lisa Murkowski—also remained up in the air, but the moderate Republican to watch more than any other appears to be Dean Heller.
The Nevada Republican is the canary in the moderate coal mine: He’s the most vulnerable Republican senator up for re-election in 2018, and he ripped the original Senate bill’s Medicaid reforms and failure to bring down premiums on the individual market. But on Thursday, he struck a much more conciliatory tone. After a long meeting in Senate majority leader Mitch McConnell’s office, Heller told reporters: “The conversations I’ve had with the leader have been very, very good.”
Asked about the Washington Post‘s report that McConnell had told moderates not to worry about Medicaid cuts because the deepest ones are far away and unlikely to take effect, Heller told THE WEEKLY STANDARD: “I haven’t heard that. I think you’re making it up.” According to Nevada’s top political journalist Jon Ralston, there is zero chance” that Heller will vote for the bill if Nevada governor Brian Sandoval opposes it, and Sandoval said Thursday he’s greatly concerned about the bill.
Another obstacle to the passage of the bill is that the Congressional Budget Office won’t provide its official score of the bill until Monday, and even then it very likely will not have analyzed the impact of the Cruz amendment. Senator Mike Enzi, chairman of the budget committee, told Roll Call that the CBO score of the Cruz amendment would “come up before we finish voting” but not necessarily before they open debate on the bill.
Finally, and perhaps most importantly, even if 50 GOP senators get behind a health care bill, the Senate parliamentarian could still rule that key provisions violate the rules governing the budget reconciliation process (which allows the Senate to pass a bill with a simple majority, rather than the typical 60 votes required to overcome a filibuster). Fox New’s Chad Pergram reported that the Senate GOP would seek formal rulings from the parliamentarian on Tuesday and vote on the motion to proceed to the bill after that.
Despite all the challenges facing the bill, McConnell vowed movement on the legislation. “We will be voting next week,” he told reporters.
This post originally appeared on Weekly Standard