The Senate is scheduled to hold its most pivotal vote yet to repeal Obamacare this week, but major questions remain over which legislation Republicans will vote on and which can pass.
On Tuesday, GOP leadership is expected to call for a vote on a procedural motion to start debate on a House-passed bill that would partially repeal Obamacare. If that motion gets the 50 votes it needs, the House bill would be stripped out and replaced, but no one is sure what the replacement will be.
Senate Republicans were thrown a major curveball Friday evening when the Senate parliamentarian ruled that key provisions in the replacement bill don’t meet the rules to use a budgetary process called reconciliation. The GOP is trying to use reconciliation to get the bill approved with only 51 votes as opposed to 60 needed to break a filibuster.
But reconciliation has certain limits, namely that provisions must apply only to budgetary and spending levels.
The Senate parliamentarian said that provisions such as defunding Planned Parenthood and funding insurer subsidies for cost-sharing reduction payments don’t meet the rules. The GOP can overrule the parliamentarian, but it is not clear if leadership intends to go down that path.
In any case, Republicans don’t have the votes to pass any healthcare reform bill currently. The GOP can afford two Republican defections out of its 52-48 majority as Vice President Mike Pence can break any ties.
Leadership is meeting to try to drum up enough support for its bill, the Better Care Reconciliation Act. It would partially repeal and replace Obamacare, but it faces key opposition from the conservative and centrist wings of the GOP conference.
Four senators — Susan Collins of Maine, Rand Paul of Kentucky, Mike Lee of Utah, and Jerry Moran of Kansas — have said they oppose the bill. However, the White House and GOP Senate leadership are in talks with holdouts to get them onboard.
Lee left a Wednesday night meeting of more than 20 Republicans saying he was optimistic. He has opposed the bill over changes to an amendment he and Sen. Ted Cruz, R-Texas, authored that lets insurers sell plans that don’t comply with Obamacare as long as they sell one that does.
The other option Senate leadership has is to bring up a 2015 bill that repeals Obamacare’s mandates and individual and employer mandates but leaves in place the law’s insurer regulations. Obamacare would remain in place for two years while senators crafted a replacement plan.
But leadership doesn’t have the votes for that approach, either. Collins and Sens. Lisa Murkowski of Alaska and Shelley Moore Capito of West Virginia publicly oppose what is called “repeal and delay.”
Capito renewed her resistance to repeal-and-delay in her weekly video address.
“I remain committed to repealing Obamacare then replacing it with a healthcare system that will continue to provide affordable care to West Virginians,” she said.
Capito added that she hasn’t made a decision on the BCRA.
“We aren’t there yet,” she said. “We are working hard to find the right solution for the country.”
Trump had called for repeal-and-delay Monday night after Lee and Moran announced their opposition to the repeal-and-replace bill. But two days later, he hosted almost all GOP senators at the White House, where he urged them to push the replacement bill through.
Leadership is pulling out all the stops to get 50 votes for the replacement bill, which involves appealing to centrists. Senate Majority Leader Mitch McConnell has some money to work with, as the latest version of the bill frees up $300 billion by keeping Obamacare’s tax on investments by higher-income earners and a Medicare surtax.
The administration is pushing a new idea called a Medicaid “wrap-around.” The idea is to allow states to use Medicaid funding, tax credits, and money from a $182 billion stability fund to reduce healthcare costs for low-income people who would be affected by the rollback of Obamacare’s Medicaid expansion.
The Better Care Reconciliation Act would start phasing out extra federal money for the Medicaid expansion in 2020 over a three-year period. After that, it would cut funding with some states facing up to a 39 percent reduction in federal Medicaid funding, according to an estimate from the consulting firm Avalere Health.
Sen. Rob Portman, R-Ohio, a key centrist holdout, called the extra funding and the wrap-around progress. He has not decided how he would vote on a motion to proceed.
Meanwhile, on the other end of the Republican ideological spectrum, senators are trying to get Lee on board.
Lee was concerned because of changes to his and Cruz’s amendment focusing on Obamacare’s insurer regulations, such as requiring insurers not to charge people with pre-existing conditions more money.
The amendment would allow an insurer to sell plans that don’t comply with certain Obamacare regulations, such as requiring the coverage of 10 essential health benefits and the requirement banning insurers from charging sick people more, as long as the insurer sold a plan that did meet all of Obamacare’s requirements.
The original amendment created two separate risk pools of plan participants. One risk pool was for the Obamacare-compliant plans and the other risk pool for noncompliant plans.
But the version that made it in the final bill has a single risk pool for both sets of plans.
Lee’s proposed changes have not been addressed, and Lee has not changed his position, a GOP Senate aide said.
Other major questions still surround the vote itself.
For one, GOP leadership has not indicated what amendment will be brought first if the motion to proceed on the House bill passes. Senate GOP leadership is pushing for members to vote on the motion to at least start debate, but it hasn’t divulged which bill it will substitute the House bill for.
It also is not clear if Sen. John McCain, R-Ariz., will return for a vote Tuesday. McCain is recovering from surgery to remove a blood clot above his eye and has been diagnosed with brain cancer.
Sen. John Cornyn, R-Texas, the Senate majority whip, told reporters last week that he expected McCain to be back.
Paul presented an idea that could win his support on the motion to proceed. He said that as long as leadership supported a vote on a clean repeal of Obamacare, he would support the procedural motion, according to a report in The Hill.
The leadership also could bring up votes on other proposals such as one from Sens. Bill Cassidy, R-La., and Collins that lets states decide if they want to keep Obamacare.
“Let’s do a random selection. Let’s have three or four of them, put them in random order, the first day, equal billing. I think that’s a compromise. I’m willing to get on the bill,” Paul said.
