In the first six months of the Trump administration, Republican leaders have pulled, delayed, and lost votes towards their ultimate goal of repealing and replacing major provisions of the Affordable Care Act. Now, the Senate is gearing up for a series of politically perilous votes in order to ultimately pass an unknown bill to allow negotiations with a House hesitant to pass whatever it is.
Members of both chambers of Congress expect that the Senate can pass only a so-called "skinny" bill that repeals a few crucial but unpleasant provisions, such as the penalties encouraging individuals to buy health insurance and large companies to offer it, and taxes like those on medical devices that reduce the deficit.
As a last resort if bicameral negotiations fail, the House could then take up the same stripped-down measure. But key moderate and conservative House Republicans cast doubt Wednesday on whether the chamber would pass such a bill.
Senate Republicans have forged a path of least resistance in limiting debate to a process that doesn't require Democratic input or votes. But they've been beset by internal divisions over how far to roll back the law’s Medicaid expansion and consumer regulations that strengthen coverage but raise premiums, especially for the young and healthy. The bills proposed by Republican leaders would increase the number of uninsured Americans over a decade by about 22 million, according to the Congressional Budget Office, after making deep cuts to Medicaid and the ACA subsidies that help Americans buy private insurance.
Passing a simple bill would avert those tough questions, and could push them to a small group of negotiators. It would face the enormously difficult task of finding the bill to deliver on Republicans’ top promise for the past seven years. And it would have to do so as the ACA’s approval rating polls at about 50 percent, which is roughly twice as popular as the Republicans’ proposals this year.
But going after unpopular portions of the Affordable Care Act would still substantially affect the health care coverage of the country. Repealing the penalty associated with the individual mandate would increase the number of uninsured Americans by millions next year, according to the CBO, although some conservatives have accused the budget scorer of overestimating its impact.
Republican Congress members were split when asked if they would support a pared-down bill repealing some taxes and penalties. Rep. Tom MacArthur of New Jersey, who helped strike a compromise between moderates and conservatives earlier this year, wouldn’t say how he would vote, but appeared pessimistic.
“I don’t know how you repeal without a responsible replacement,” he said. “I don’t know that just lifting mandates and some of the taxes—that puts more stress on the current system. I’m interested in fixing the health care system, not making the current system worse.”
Unruly conservatives such as Rep. Mark Meadows, leader of the House Freedom Caucus, said the bill wouldn't pass the House.
“It doesn’t go to the president,” said Meadows.
But other Republicans aligned with President Trump and House Speaker Paul Ryan said they'd be open to a skinny, rather than an ambitious, bill.
“If the worst that happened is we had to vote on their skinny repeal, that’s clearly better than nothing,” said Rep. Chris Collins of New York, an early supporter of Trump’s presidential campaign.
“We just can’t do nothing,” added Rep. Dennis Ross of Florida, a whip. “I still believe and maintain that any little bit that we do is better than doing nothing.”
The Senate Republican leadership has yet to unveil the skinny bill, but aspects of it have been described by senators, House members, and lobbyists monitoring the debate. Still, it’s not clear that such a bill would pass the Senate, even as it’s considered the most likely option. The House considered a similar bill in 2015 that would cut the 2010 health care law’s taxes, but conservative Sens. Mike Lee of Utah, Ted Cruz of Texas, and Marco Rubio of Florida opposed it.
Cruz wouldn’t say how he’d vote on a bill that hasn’t been released. “It depends what’s in it,” he said.
What is clear is that Republicans have shifted from their old goal of outright repealing Obamacare. On Wednesday, the Senate voted against repealing the law without a replacement plan, a bill similar to the one that ultimately passed the Senate in 2015, which was vetoed by President Obama. Seven Republicans voted against the measure, underscoring their need to find an alternative and, so far, elusive solution.
“Pilots like to know where they’re going to land when they take off, and we should too,” said Sen. Lamar Alexander, the top Republican on the health care committee, in a statement.
One moderate Republican who opposed the health care bill passed earlier this year, Charlie Dent of Pennsylvania, mused on the Senate’s secretive machinations.
“It’s better than what they were considering,” he said. “Are they actually going to pass something?”