The divisions among Senate Republicans on their health care bill to change the U.S. health insurance system can be summed up as the interests of the “Wait and See” caucus versus the “Not Yet” quartet.
Four members on Thursday, just hours after the text of the draft was posted online, said they are “not yet ready” to vote for the proposal that would make significant changes to the Medicaid program and alter some aspects of the current health care law.
“There are provisions in this draft that represent an improvement to our current healthcare system but it does not appear this draft as written will accomplish the most important promise that we made to Americans: to repeal Obamacare and lower their healthcare costs,” Sens. Mike Lee of Utah, Ted Cruz of Texas, Rand Paul of Kentucky and Ron Johnson of Wisconsin said in a release.
The quartet wields enough influence to sink the legislation should they all choose to vote against the bill. Senate Majority Leader Mitch McConnell has signaled he will bring it to the chamber floor for a vote late next week. Under the fast-track budget procedure known as reconciliation that the GOP is using to advance the bill, McConnell can afford only two defections, which would give him 50 votes and allow Vice President Mike Pence to break the tie.
But equally as important will be the viewpoint of members McConnell has sought to woo by making several changes from the House-passed repeal bill. Whether those new policies are enough to convince skeptical Republicans such as Susan Collins of Maine, Lisa Murkowski of Alaska, Dean Heller of Nevada and Shelley Moore Capito of West Virginia remains to be seen.
“I see some positive features in this bill that are an improvement over the House and I see some negatives,” Collins told reporters. “I have not yet had the opportunity to read the text of the bill and the details really matter. This is extremely complex. I also want to consult with stakeholders back home in Maine.”
“At first glance, I have serious concerns about the bill’s impact on the Nevadans who depend on Medicaid,” Heller, arguably the most vulnerable Republican up for re-election in 2018, said in a statement. “If the bill is good for Nevada, I’ll vote for it and if it’s not — I won’t.”
The draft measure would maintain the Medicaid expansion included in the 2010 health care law until 2021 and then gradually phase out federal funding to states over three years until it reaches pre-law amounts. It would also impose a stricter spending limit for the entitlement program in 2025.
The proposal would keep the current law’s subsidies that help individuals afford insurance in place until 2020, when the limit on qualification for the tax credits would be lowered from 400 percent to 350 percent of the poverty line. It would also provide up to $112 billion over several years to help stabilize the insurance markets created by the 2010 law and help states lower premium costs.
An analysis from the nonpartisan Congressional Budget Office is expected early next week and an updated bill could come within the same time frame.
“I think there can be a bill that the majority leader will file maybe as late as Tuesday that would encompass additional conversations and ideas between now and then,” Senate Majority Whip John Cornyn of Texas said Thursday.
While the concerns of Lee, Cruz, Johnson and Paul may vary, a common thread is the continuation of several key aspects of the health care law and whether the current draft would actually lower monthly premium costs.
“I think the bill needs to look more like repeal and less like we are keeping Obamacare,” Paul told reporters. “Now that it is known that there is not 50 votes for this, I hope that those who are writing the bill, who have written the bill, will negotiate this.”
Johnson said GOP leaders seem “amenable” to changes, but said they provided no indication of whether the timeline for a vote would be delayed amid the concerns from the conference.
“How you rush this thing through and take a vote at the end of the next week is really beyond me,” the Wisconsin Republican said. “They seem to think there will be plenty of time. I’ll take them at their word.”
For moderates, one key question is how their states will be affected by the significant reduction in federal Medicaid funding over the next several years.
Asked about concerns that conservative Republicans may seek to amend the draft to move provisions further to the right, Capito said she would have issues with language that could “imperil” Medicaid benefits in her state.
“I think obviously Medicaid expansion and the opioid issues are the areas of greatest concern for me and folks in my state,” the West Virginia Republican said.
Both Collins and Murkowski have also raised initial concerns around language in the bill that would prohibit federal funding for Planned Parenthood for one year.
One way leadership may seek to corral votes of senators whose states expanded Medicaid under the 2010 health care law is through additional funding to help combat the opioid epidemic. The proposal currently includes only $2 billion for drug treatment, but Cornyn said it is possible extra funding could be provided in this bill or the annual spending bills.
Such a move could ease initial concerns from Ohio Sen. Rob Portman.
“There are some promising changes to reduce premiums in the individual insurance market, but I continue to have real concerns about the Medicaid policies in this bill, especially those that impact drug treatment at a time when Ohio is facing an opioid epidemic,” Portman said in a statement.
Leadership faces a difficult calculus in balancing the needs of those wanting a more aggressive repeal and those who are more comfortable with aspects of current law. Several additions that Paul, Lee and others would likely support, such as the repeal of several of the law’s requirements on insurance plans, could face backlash from those concerned about people being charged more for pre-existing conditions, for instance.
The one thing members across the political spectrum can agree on, however, is that changes to the legislation are expected.
“There will certainly be changes made and I don’t think anyone is pretending otherwise,” Sen. Marco Rubio, R-Fla., told reporters. “There are items that I’m pretty sure are going to have to be changed in order to get to 50 votes and there will probably be some changes that will have to be made in order to make it better for Florida.”
Niels Lesniewski, Sandhya Raman and Andrew Siddons contributed to this report.