Senate Majority Leader Mitch McConnell unveiled a revised bill to “repeal and replace” the Affordable Care Act Thursday, setting up a crucial vote next week on the Republicans’ top priority in Congress. But the bill maintains deep cuts to Medicaid, daring a group of GOP senators representing states that expanded the public health program for low-income people to vote against it.
The bill represents an ideological gamble by McConnell, who decided to maintain the Medicaid cuts decried by moderates while acceding to the wishes of two key conservatives, Sens. Ted Cruz and Mike Lee, by including language allowing individuals to receive tax credits to help them buy skimpier plans than are currently permitted under Obamacare.
Since two Republican senators—Susan Collins of Maine and Rand Paul of Kentucky—have already come out against the bill, McConnell will have to run the table with every other Republican senator to get the 50 votes necessary for passage.
Collins, a moderate, cited the Medicaid cuts as a major reason why she came out against the bill.
“I’m still deeply concerned about the Medicaid cuts that are included,” said Collins. “They have been modified in some ways, but there’s no doubt in my mind that there are hundreds of billions of dollars of cuts in the Medicaid program that would shift costs onto state governments.
“It would hurt the most vulnerable citizens,” she added. “It would have an adverse impact, particularly on our rural health care providers, our hospitals, and our nursing homes. And it is not something that I can support.”
The nonpartisan Congressional Budget Office reported that a previous version of the bill would cut $772 billion from Medicaid over the next decade, resulting in 15 million fewer people covered under the program. (Another 7 million more Americans would be uninsured due to reforms to the individual market.) The CBO will release its score of the revised bill next week.
The Senate Republican bill, known as the Better Care Reconciliation Act, added an additional $70 billion to the original $112 billion to prop up the individual market, which could help attract the support of some senators. But the bill would still dramatically reform Medicaid from an open-ended entitlement to a capped or block-grant system, and eventually roll back the expansion under the ACA. A group of senators representing expansion states, including Sens. Rob Portman of Ohio, Shelley Moore Capito of West Virginia, Dean Heller of Nevada, and John Hoeven of North Dakota huddled with McConnell on Thursday afternoon. Those four senators opposed the previous version of the bill.
On Thursday, some of these senators stated that they were undecided on even a procedural vote to advance the bill forward.
Heller, who had come out forcefully against the first draft of the health care bill, told reporters on the way out to his car Thursday evening that he was also undecided. “There will be a lot of meetings, and it will include discussions with the governor,” he said. But he would not say whether he would support the bill if Nevada Gov. Brian Sandoval opposes it.
Sandoval, the incoming chair of the National Governors Association, told National Journal Thursday that he had not had a chance to review the bill but that funding for Medicaid "has been a priority for me, to protect the 200,000-plus lives that benefit as a result of the expansion."
Senators will have the opportunity to change the bill through amendment. The Medicaid-expansion-state senators want to increase per-enrollee payments through Medicaid; currently the bill would eventually peg the formula to consumer rather than medical inflation, which grows faster. But other conservatives have objected. The original bill would reduce the deficit by $321 billion over a decade, in large part due to the Medicaid cuts, according to CBO.
On Thursday, Sen. Bill Cassidy of Louisiana noted that the significant changes to the Medicaid growth rate begin in 2025. “If it doesn’t work, we have eight years to kind of figure that out,” he said.
Overall, the Senate’s process to reform health care has been secretive, shunning congressional hearings and other measures that allow the debate to be analyzed before the public. The closed-door negotiations have resulted in a bill criticized by major hospital, doctor, and patient-advocacy groups. In June, multiple polls showed fewer than 20 percent of respondents supporting the Senate bill.
On Thursday, AARP, the largest nonprofit advocacy group for those above the age of 50, was one of multiple outside groups that blasted the revised bill.
“AARP also remains alarmed at the Senate bill’s drastic Medicaid cuts,” said AARP Executive Vice President Nancy LeaMond in a statement. “The proposed cuts would leave millions of Americans, including 17.4 million poor seniors and people with disabilities, at risk of losing the care they need and their ability to live independently in their homes and communities.”