After seven years of promising to “repeal and replace” Obamacare, the Republican leaders in the Senate finally unveiled a bill Thursday they said would do just that. But the bill wasn’t public for four hours before four conservative senators announced their opposition, threatening the Trump administration’s top priority in Congress.
The senators—Ted Cruz of Texas, Rand Paul of Kentucky, Mike Lee of Utah, and Ron Johnson of Wisconsin—oppose the current legislation for a variety of reasons. Should they get what they want, the bill would move further to the right, further antagonizing the Republican senators who are already wary of supporting a bill that would eliminate Medicaid coverage for millions.
Rank-and-file senators have been frustrated with how the Republican leadership crafted the bill, which did not receive a hearing in a major departure from the normal legislative process. “How you rush this thing through and take a vote at the end of next week is really beyond me,” said Johnson, who wants more information and more time to evaluate the draft with his governor and state. The Congressional Budget Office plans to score the bill by early next week, perhaps a couple of days before senators vote on it.
But Sen. John Cornyn, the No. 2 Republican, said Thursday that despite his colleagues’ concerns, the Senate will still vote on the bill next week before members go home for the July 4 recess.
“It doesn’t get any better,” said Cornyn. “It doesn’t get any easier.”
The draft legislation would eliminate the Affordable Care Act’s penalty urging Americans to purchase health care insurance and the penalty requiring large companies to provide it. It would cut billions of dollars in federal funding for Medicaid by eventually eliminating the ACA’s Medicaid expansion and changing the public program for low-income people from an open-ended entitlement to a per capita or block-grant program. It would cut taxes primarily on the affluent used to pay for the ACA and reduce the subsidies helping Americans purchase health care on the federal exchanges. It would allow states to waive some policies, including requiring insurers to provide for essential health benefits such as maternity treatment. And it would keep some popular provisions, such as allowing children to stay on their parents’ insurance until they’re 26.
Some conservatives who had derided the House’s bill as “Obamacare-lite” would like to make further changes. In the meeting with his fellow Republican senators Thursday morning, Lee talked about his “need” to repeal all the Title I regulations, which includes provisions eliminating lifetime annual limits on benefits and extends dependent coverage up to age 26, according to a Lee aide. After the meeting, Paul released a statement saying the bill “does not keep our promises to the American people” as it “does not repeal Obamacare.”
One editor from the libertarian Reason magazine said it might be “Obamacare lite—later,” noting the delays in many of the bill’s provisions. Another from the Washington Examiner tweeted it “does more to rescue Obamacare than it does to repeal it.”
Outside groups like FreedomWorks echoed Paul’s message, while health care experts from the Heritage Foundation said the bill should expand its waiver authority.
If the bill went to the floor today, it wouldn’t pass, since Republicans can only afford to lose two out of 52 GOP senators with zero Democratic support. And even if it could, it also likely wouldn’t be able to pass the House over conservatives’ concerns there. “I think we're probably going to get a lot of push back from people from the Right in the House,” said Sen. Lindsey Graham.
Rep. Mark Meadows, the leader of the House Freedom Caucus, said the “majority” of his arch-right group would support the bill if Cruz is successful in inserting “consumer choice” provisions. Meadows said the amendments would allow for insurers to compete across state lines and allow people to use subsidies to purchase a plan that doesn’t meet the ACA’s standards.
“We should do more to ensure consumers have the freedom to choose among more affordable plans that are tailored for their individual health care needs,” said Cruz in a statement. “As currently drafted, this bill draft does not do nearly enough to lower premiums.”
Still, conservatives are hopeful that they can still get support for the ultimate bill in order to deliver on their promises. Cruz, who’s up for reelection, noted that he’s worked on this bill for four months. While Cruz has antagonized his leadership almost since he got to the Senate, Cornyn says he’s “convinced” his colleague from Texas “wants to get to yes.”
Of course, it may not be enough. Other Republicans, such as Sens. Rob Portman and Shelley Moore Capito, have their own concerns, including increasing the funding to combat the opioid crisis. Moderate Sen. Susan Collins wants to examine the impact on insurance coverage; the House legislation increased the number of uninsured by 23 million. And Sen. Dean Heller, perhaps the most vulnerable Republican up for reelection, has “serious concerns” about the bill’s effect on his state, which saw 200,000 Nevadans get insurance under the Medicaid expansion.
And other conservatives besides Cruz might already be gone.
“Senator Paul, I think, has unique concerns that aren’t necessarily shared by the others,” said Cornyn.