WASHINGTON — Senate Republican leaders are set to release details of their legislation to repeal and replace the Affordable Care Act after weeks of closed-door negotiations. Republican senators will receive the legislation first in a meeting at 9:30 a.m. Thursday with the first public glimpse at the proposed bill coming shortly afterwards.
The process could then move quickly, with a vote on the bill coming as early as next week.
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Republican senators weren't talking about the plan on Wednesday, saying they were waiting to see the details themselves. "We'll know if it's a boy or girl tomorrow about 9:30,” Sen. Lindsey Graham, R-S.C., said.
The process has been criticized by Democrats and even some Republicans anxious to know specifics about a bill that would impact millions of Americans. Despite participating in some discussions on what a bill should look like, Republican members outside a small group of leaders have not been privy to the final contents.
Some Republicans have expressed frustration with the process.
“You know, I woke up this morning and I decided I was going to make my day so much easier by letting all of you inquiring minds know that today I don’t know anything more than I knew yesterday,” said Sen. Lisa Murkowski, R-Alaska. “Tomorrow I’m going to know so much more and I’ll have such better response to all of your questions. I’m most eager to entertain them then.”
When asked if she wishes she knew more, Murkowski said, “I do.”
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Senate Majority Leader Mitch McConnell has been overseeing the construction of the legislation in an effort to cobble together the votes of at least 50 Republicans who have vastly different positions on what health care should look like.
McConnell has kept details under wraps, presenting his conference with options being considered instead of final decisions, especially on some of the most difficult components to hash out.
As Congress and the public awaits the details, here are some details and dynamics to watch:
The Big Issues
Medicaid: Medicaid has been a major issue of contention since the Senate received the House-passed version of the bill last month. Senators from states who expanded Medicaid under Obamacare have come to like the expansion and don’t want to kick people off the program for low-income and disabled Americans. Senators from states that didn’t expand don’t want to be penalized by receiving less federal funds by choosing not to expand the program.
Republican leaders trying to accommodate both sides are contemplating a slow winding-down of Medicaid, making the program less generous or creating carve outs to ensure that certain groups of people don’t lose coverage, such as children with chronic health care needs.
“I don’t know where they’re going to come out on that,” Sen. Rob Portman, R-Ohio, said. “Cutting the growth rate means that states wouldn’t be able to keep the same number of people on Medicaid without finding additional resources and that’s a challenge.”
Tax Credits: The Republican bill is expected to help people in the individual markets purchase insurance through assistance based on income. The House version of the health care bill provides tax credits based on age, leaving older people with higher costs. The Senate is trying to correct that.
Taxes: Not all Obamacare taxes will be repealed, at least not immediately, to help pay for the Senate bill. Senator Bill Cassidy, R-Louisiana, wants to repeal the taxes that he believes increase the cost of premiums, including the tax on health insurance companies, pharmaceuticals and medical devices — those are also the taxes on companies with powerful lobbyists. Democrats say the House health care plan is nothing more than a tax cut for the wealthy because of it repeals all taxes, including a 3.8 percent tax on the wealthy.
Opioid Funding: Another concern about cutting Medicaid funding is that treatment for opioid addition would lose funding. An option that has been floated is creating a pot of money, at least $15 billion per year, to be available for that purpose. Senators from states with high opioid addiction rates are hoping that people with addictions don’t lose their access to care.
Planned Parenthood: Conservatives want to strip Planned Parenthood funding from the health care bill but moderates are opposed to that. The Senate bill will try to appease both of them.
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Senators to Watch
Different factions of senators are critical to the passage of the bill and all of the members below could easily vote against it.
Moderates: Sens. Susan Collins of Maine, Lisa Murkowski of Alaska, Shelley Moore Capito of West Virginia and Rob Portman of Ohio. These members have various concerns but one similar thread is the threat of drastic cuts to Medicaid.
Conservatives: Sens. Mike Lee of Utah, Rand Paul of Kentucky, Pat Toomey of Pennsylvania and Tom Cotton of Arkansas. Like the moderates, they all have different concerns but generally they want greater cuts to Medicaid and fewer mandates on coverage and less government assistance.
“My main concern is I promised voters that I would repeal Obamcare and everything I hear sounds like Obamacare light,” said Sen. Paul. “I’m still hoping we reach impasse and we actually go back to the idea we originally started with which was repealing Obamacare.”
Vulnerable Members: Sens. Jeff Flake of Arizona and Dean Heller of Nevada could have tough re-elections in 2018 and a vote for an unpopular bill could seal their fate.
The Congressional Budget Office must release a cost and coverage estimate before the Senate votes. That report could come out as early as Friday or Monday. McConnell could then bring up the legislation on Wednesday, which is expected to take two to three days to debate and vote on.
But if the Senate passes it, the House and Senate have to reconcile the differences in their bills. The House has two options: either vote on the Senate bill, which could be a heavy lift after a difficult vote in the House just a month ago, or the two bodies go to conference, come up the exact same bill and then each body votes on it again.
In other words, it’s still a long road to the president’s desk.