Voting to start work on a healthcare reform bill was tough enough, but actually passing a bill in the Senate is likely to be even tougher, as it will require Republicans to overcome major hurdles, including a split within the GOP.
Centrist Republicans remained worried about possible cuts to Medicaid and the rollback of the program’s expansion under Obamacare, while conservative Republicans fear it won’t do enough to reduce the costs of premiums and undo Obamacare.
The first amendment to be considered will be the “repeal and delay” strategy that would give Congress two years to draft a plan to replace Obamacare. But that is likely to fail, as Sens. Susan Collins of Maine, Lisa Murkowski of Alaska, Shelley Moore Capito of West Virginia and others oppose that idea.
After that, senators will be looking to toss in their different, competing ideas on how to reform the healthcare system.
Sen. Ted Cruz, R-Texas, for instance, said in a statement that he would vote for the 2015 repeal-and-delay bill or the Better Care Reconciliation Act if it includes the amendment he proposed and incentivizes the use of health savings accounts. He called Tuesday’s motion a “critical step in the right direction.”
Another amendment, from key centrist Sen. Rob Portman of Ohio, would add $200 billion to Medicaid.
But neither of these amendments have been scored by the Congressional Budget Office, meaning that both would need 60 votes to pass, an impossibility given opposition from Democrats. Sen. John Cornyn, R-Texas, told reporters that one option around this problem could be to send the bill to conference with the House, which would buy more time for a CBO score on both amendments.
Other amendments are likely to receive votes, but it is not clear which ones can pass.
One amendment proposed by Sens. Bill Cassidy of Louisiana and Lindsey Graham of South Carolina would take funding from Obamacare and allow states to determine how to use it. Sen. John McCain, R-Ariz., who made a dramatic return to the Senate to help advance the bill after his cancer diagnosis, has said that he would propose an amendment but hasn’t shared the details.
Another hurdle is lurking that could prevent votes on any of these amendments. The Senate parliamentarian has not made a determination on whether the provisions meet reconciliation rules, which require that the bill target only items that have to do with the federal budget.
Several of the provisions that Republicans have discussed are unlikely to pass that test, including anti-abortion provisions, a measure to charge seniors higher premiums, and a provision that would let small businesses bypass Obamacare insurance rules.
In light of these problems, speculation mounted Tuesday that the final product will be a “skinny repeal,” which would undo Obamacare’s employer and individual mandates and repeal the medical device tax.
The Congressional Budget Office has estimated that undoing the individual mandate, which requires people to purchase insurance or pay a fine, could cause as many as 16 million people to be uninsured next year. Some, they project, would choose not to buy insurance, while others would see prices rise and be unable to afford premiums.
The difficulty of finding agreement among Republican senators could be seen in the run-up to Tuesday’s vote. Vice President Mike Pence met with the entire GOP conference during a luncheon ahead of the vote, and leadership put pressure on holdouts to vote to at least start debate on repealing Obamacare.
Republicans were just barely able to get the Senate on the bill with a 50-50 vote that needed Pence to break the tie. Republicans had 48 votes with just Sens. Ron Johnson, R-Wis., and McCain left to vote.
McCain was en route to the Capitol, having traveled from Arizona after recovering from blood clot surgery, but Johnson was engaged in an animated discussion with Senate Majority Leader Mitch McConnell and Cornyn.
Cornyn after the vote that he believed Johnson was always going to vote yes on the motion, but that doesn’t mean he wasn’t nervous.
“We knew we had no margin for error, and so it was a tense moment to be sure,” he said, adding that Johnson has complained about the process leadership has used to get the bill to the floor.
Johnson recently said that McConnell committed a “breach of trust” when he told centrists that the steep Medicaid cuts weren’t likely to go into effect by the time expansion funding is fully phased out in 2023. But Cornyn downplayed that.
“I think he just wanted to have a conversation to talk about his concerns,” Cornyn said.
Johnson said the conversation was more positive.
“I want to talk to the leader about being a positive influence on the process,” he said. “I got the feeling that he would appreciate that.”
When he was asked about the body language between himself and McConnell that seemed to indicate the conversation was tense, Johnson responded, “I don’t think it was a heated discussion at all.”
