A new draft of the bill Republicans are advancing to repeal and replace portions of Obamacare, released Thursday, leaves in place taxes on high-income earners, pumps more money into opioid treatment and insurance markets, and allows customers to use subsidies toward the purchase of less expensive plans that cover fewer medical services.
An amendment as proposed by GOP Sens. Ted Cruz of Texas and Mike Lee of Utah was tweaked in the new draft. As proposed, the Cruz-Lee amendment would have allowed health insurance companies to offer less-expensive plans that do not include Obamacare's essential health benefits as long as they provide at least one plan that includes them. Critics blasted the proposal, saying it would make plans for people with pre-existing conditions prohibitively expensive.
According to the draft, the legislation would set up a fund that would make payments to insurers to help cover the cost of high-risk, disproportionately expensive customers who are enrolled in the exchange. To qualify, an insurer will need to offer minimum coverage that has a wide range of medical benefits and cover people with pre-existing illnesses. They could offer coverage off the exchange that would be exempt from nine requirements.
Lee, who has indicated he couldn't support the bill without the Cruz-Lee amendment, said on Twitter before the bill's release that he hadn't seen the new version and would withhold judgment until he does.
Senate Majority Leader Mitch McConnell, R-Ky., was not previously able to gain enough Republican support for a former version of the bill and moved back the Senate's August recess partly to work on reaching an agreement. Republicans are advancing the bill through reconciliation, which requires only a simple majority vote rather than the 60 typically needed to kill a filibuster. Because no Democrats will vote for a bill that repeals Obamacare, Republicans can pass a law only with their own party, which holds a narrow majority, at 52 seats.
In attempting to bring the party to a "yes" vote, the latest draft includes changes that were made to win over more centrist members. For instance, it leaves in place Obamacare's taxes on high-income people, including the investment income tax, the Medicare Health Insurance Tax and the remuneration tax on executive compensation for health insurance executives. The changes help raise more money and Republicans hope will blunt attacks that their legislation is aimed as cutting healthcare to the poor to deliver tax cuts to the wealthy.
The latest draft of the bill, the Better Care Reconciliation Act, would provide an additional $70 billion to states that they could use toward reducing premiums, helping residents set up health savings accounts or any other innovations that would reduce costs and stabalize the insurance market. The initial draft provided $112 billion in funding for those purposes.
As has been previously reported, the bill provides $45 billion to fund treatment for people who have opioid addictions.
For private coverage, a provision was added that would allow people to use health savings accounts to pay for their premiums, a move that the Joint Committee on Taxation said would increase healthcare coverage, according to an outline describing changes to the legislation.
People would be allowed to enroll in catastrophic healthcare coverage and would be eligible for a tax credit to pay for it, an option not available under Obamacare. They also would have the option of purchasing a lower-premium plan, which likely would cover fewer medical services and include higher deductibles. These plans would be required to cover three primary care visits a year and limit out-of-pocket costs.
On federal funding for low-income populations, the bill would allow Disproportionate Share Hospital payments to fund hospitals for uncompensated care, but changes the calculation from per Medicaid enrollee to per uninsured.
The bill did not include any changes to plans for revamping Medicaid that were in the previous version of the bill, which centrists have increasingly raised concerns about.
"Every action has an equal and opposite reaction, it seems," Sen. John Cornyn, R-Texas, said about indications that centrists are unhappy about the Medicaid cuts being left in the bill.
Under the initial draft, Medicaid expansion would be rolled back in states that expanded it to low-income residents under Obamacare. It also over the long term allows states to choose between receiving a fixed amount of federal dollars from Medicaid as a per-capita cap or a block grant, and re-configures the program's growth rate to match overall inflation rather than to its current, faster-increasing medical inflation.
States will be able to apply for a waiver if they need to improve care for people who are older, blind or disabled. In the case of a public health emergency, like Zika, state spending on these programs will not come out of the Medicaid structure that they choose, whether per-capita cap or block grant. States that have expanded Medicaid will be able to apply for more block grant funding if they choose this option.
The GOP plan includes a repeal of the employer mandate and the individual mandate, which requires people to obtain insurance or pay a fine. Provisions involving restrictions on abortion also were included in the second draft. Tax credits to help pay for healthcare plans could not go toward plans that offer abortions, and federal funding for family planning services, like contraception and cancer screening, would be cut off for one year from facilities that also provide abortions. It's not clear if the provisions would pass the rules needed to pass the bill through reconciliation.Planned Parenthood President Cecile Richards called the draft "the worst bill for women in a generation ... and blocking millions from getting preventive care at Planned Parenthood would result in more undetected cancers and more unintended pregnancies."
The final bill could change significantly as Republicans evaluate its provisions and see results from the Congressional Budget Office, which would evaluate the impact the legislation would have on the uninsured rate and on federal spending. The score is expected in coming days.
"I think all of these things are subject to an amendment," Sen. John Thune, chairman of the Senate Republican Conference, told reporters. "This is a far cry from a finished product."
Before heading to a floor vote, which Senate leaders hope to have next week, Republicans will need to vote on a motion to proceed that would bring the legislation forward for debate. Several Republicans are likely to wait to voice their support or opposition for proceeding until they see how the CBO scores the bill.
Some divisions became apparent early. The amendment and other changes were not enough to win over Sen. Rand Paul, R-Ky., who said he remains steadfastly opposed to the new bill because he believes it does little to repeal Obamacare.
"I can't object more strongly than I am against this bill," he said on the Laura Ingraham show Thursday. "A vote for this is a breaking of a promise we made to voters."
Indicating further divisions, GOP Sens. Bill Cassidy of Louisiana and Lindsey Graham of South Carolina released an alternate healthcare plan Thursday morning. The legislation would send revenue from Obamacare's taxes for states to use to craft their own health plans.
Graham told reporters that the bill could be added as an amendment to the Better Care Reconciliation Act, and he and Cassidy said they hoped it would receive bipartisan support.
*Robert King contributed to this report.