Trump suggests Republicans will let ACA market collapse, then rewrite health law

(THIS ARTICLE IS COURTESY OF THE WASHINGTON POST)

Power Post

Trump suggests Republicans will let ACA market collapse, then rewrite health law

 July 18 at 10:52 AM
President Trump predicted Tuesday morning that Republicans may wait for the federal insurance market to collapse and then work to broker a deal to rewrite the nation’s landmark health-care law.In a series of tweets, Trump blamed the demise of a months-long effort to rewrite the Affordable Care Act on Democrats “and a few Republicans,” but he suggested that the drive to overhaul the law was not completely over.

“We were let down by all of the Democrats and a few Republicans. Most Republicans were loyal, terrific & worked really hard. We will return!” he tweeted. He added in a separate tweet: “As I have always said, let ObamaCare fail and then come together and do a great healthcare plan. Stay tuned!”

Trump’s latest comments appeared likely to intensify the current political uncertainty on Capitol Hill, where GOP leaders were debating what to do next, as well as raise anxiety among insurers that must commit to staying on the federal health exchange within a matter of weeks.

Republicans are reeling after two more GOP senators declared their opposition Monday to the party’s plan to overhaul the nation’s health-care system, likely ending their quest to make good on a GOP promise that has defined the party for nearly a decade and has been one of Trump’s top priorities.

Two Senate Republicans oppose health-care bill, jeopardizing vote
The U.S. Senate’s healthcare overhaul appears to be in trouble after two more Republicans say they oppose a revised version of the bill. (Reuters)

Senate Majority Leader Mitch McConnell (R-Ky.) opened the Senate on Tuesday morning touting his latest plan — to vote on a pure repeal, with a two-year delay, by taking up the House’s health-care bill. But while conservatives and Trump have been pushing for such a repeal as a last resort, it appeared unlikely that the vote would succeed.

Two Republican senators, Susan Collins (Maine) and Shelley Moore Capito (W.Va.), expressed opposition Tuesday to the repeal-only option, apparently burying it.

“I did not come to Washington to hurt people,” Capito said on Twitter. “I cannot vote to repeal Obamacare without a replacement plan that addresses my concerns and the needs of West Virginians.”

“This doesn’t have to be the end of the story,” McConnell said. “Passing the repeal legislation will allow us to accomplish what we need to do on behalf our people.”

McConnell said the Senate would next take up “a repeal of Obamacare combined with a stable two-year transition period.” He said that President Barack Obama had vetoed such legislation before but that “President Trump will sign it now.”

While he noted that the measure had overwhelming support among Republican senators in 2015, the Senate leader also acknowledged that his party has suffered a political setback.

“I regret that the effort to repeal and immediately replace the failures of Obamacare will not be successful,” he said. “We will now try a different way to bring the American people relief from Obamacare.”

Republican Sens. Mike Lee (Utah) and Jerry Moran (Kan.) issued statements Monday declaring that they would not vote for the revamped measure. The sudden breaks by Lee, a staunch conservative, and Moran, a McConnell ally, rocked the GOP leadership and effectively closed what already had been an increasingly narrow path to passage for the bill.

They joined Sens. Rand Paul (Ky.) and Collins, who also oppose the latest health-care bill. With just 52 seats, Republicans can afford to lose only two votes to pass their proposed rewrite of the ACA. All 46 Democrats and two independents are expected to vote against it.

Lee supports the idea of moving ahead with a straight repeal of the existing law, and his spokesman, Conn Carroll, said Tuesday he would back a motion to proceed on a bill that would achieve that aim. But many centrist Republican senators have said they oppose dismantling key aspects of the ACA without an immediate replacement, given that roughly 20 million Americans have gained coverage under the law.

The confusion over next steps highlights the predicament now faced by Republicans, who have made rallying cries against Obama’s 2010 health-care law a pillar of the party’s identity. They may be forced to grapple with the law’s shift from a perennial GOP target to an accepted, even popular, provider of services and funding in many states, which could make further repeal revivals difficult.

Meanwhile, Trump and other Republicans will confront a Republican base that, despite fervent support for the president, still seeks a smaller federal government and fewer regulations.

All of these forces remained vexing factors Monday as senators bailed on the bill. And no evident solution was offered by the White House — which has been limited in its sale of the GOP plan — or from McConnell, for how to bring together a party in which moderates and conservatives are still deeply divided over the scope of federal health-care funding and regulations.

In many ways, the leadership plan did not go far enough for those on the right, but was too radical for GOP centrists. It scaled back some key ACA requirements and made deep cuts over time in Medicaid, but preserved popular provisions of the law such as a ban on denying coverage to consumers with costly medical conditions.

But the fact that it would reduce federal Medicaid funding and phase out the program’s expansion in 31 states and the District of Columbia rankled several key GOP governors and senators, who feared that their states would be saddled with the unpalatable choice of either cutting off constituents’ health coverage or facing a massive new financial burden.

The opposing pressures have left McConnell in a tough position as he has struggled to find a solution, which is why he has now thrown out the idea of moving to an immediate repeal.

Abolishing several of Obamacare’s central pillars — including the mandate that taxpayers buy coverage, federal subsidies for many consumers’ premiums and Medicaid coverage for roughly 11 million Americans — could wreak havoc in the insurance market. A Congressional Budget Office analysis in January estimated that premiums in the individual insurance market would rise between 20 and 25 percent next year and would roughly double by 2026.

At the same time, according to the CBO, the number of uninsured would spike by 18 million next year and rise to 32 million by 2026.

“For insurers, the worst possible outcome in this debate has always been a partial repeal with no replacement, which is exactly what Congress is about to take up,” said Larry Levitt, senior vice president for special initiatives at the Kaiser Family Foundation, in an email. “Insurance companies would be on the hook for covering people with preexisting conditions, but with no individual mandate or premium subsidies to get healthy people to sign up as well.”

But GOP leaders had no choice but to shift gears after Lee and Moran declared they could not support the party’s current health plan.

“In addition to not repealing all of the Obamacare taxes, it doesn’t go far enough in lowering premiums for middle class families; nor does it create enough free space from the most costly Obamacare regulations,” Lee said in a statement.

Moran said the bill “fails to repeal the Affordable Care Act or address healthcare’s rising costs.”

The two senators timed the release of their statements and made clear that modest tinkering around the edges of the legislation drafted by McConnell would not be enough to meet their demands. They joined a pair of GOP colleagues in calling for a complete redrawing of the legislation that would take many months, short-circuiting McConnell’s wish to end the debate this month.

The news threw the effort to pass the legislation into turmoil, with additional Republicans weighing in on Twitter about a flawed process that must take a new direction. Trump tweeted late Monday that “Republicans should just REPEAL failing ObamaCare now & work on a new Healthcare Plan.”

Sen. Lindsey O. Graham (S.C.) called for a “new approach” while Rep. Mark Meadows (N.C.) tweeted, “Time for full repeal.” White House aides, meanwhile, said they still plan to press ahead.

The setbacks appear to have left McConnell and House Speaker Paul D. Ryan (R-Wis.) with few good options. Conservatives have suggested moving a bill that would simply repeal the Affordable Care Act and set up a timeline of several years to figure out how to replace it, a politically risky move that also might lack support to pass.

Another move, which McConnell threatened recently, would be to work with Democrats to prop up the insurance exchange markets that have been imploding in some states — which probably would win passage but would infuriate the conservative base that has been calling for the end of the Affordable Care Act.

“Regretfully, it is now apparent that the effort to repeal and immediately replace the failure of Obamacare will not be successful,” McConnell said in a statement released late Monday. He revealed plans to move forward with a vote in the coming days anyway, in some ways daring his Republican opponents to begin debate and open the legislation up to amendments.

Democrats quickly jumped at the opportunity to declare the effort dead.

“This second failure of Trumpcare is proof positive that the core of this bill is unworkable,” said Minority Leader Charles E. Schumer (N.Y.). “Rather than repeating the same failed, partisan process yet again, Republicans should start from scratch and work with Democrats on a bill that lowers premiums, provides long-term stability to the markets and improves our health-care system.”

But Ryan showed little interest Tuesday in making common cause with Democrats, telling reporters that House leaders “would like to see the Senate move on something” to keep the repeal-and-replace process alive.

In a closed-door conference meeting, according to several members present, Ryan told colleagues that the ball remains in the Senate’s court and announced no plans for further action on health care in the House. He also urged House members to be patient and not to openly vent frustration with the Senate, the members said.

Publicly, he emphasized that the Senate had “a razor-thin majority” and that passing legislation is “a hard process.”

Republican leaders had returned to the Capitol on Monday still pledging to press ahead with plans to pass a far-reaching overhaul, but the day had begun with uncertainty as the health of Sen. John McCain (R-Ariz.) put the future of the flagging effort deeper in doubt.

In a speech on the Senate floor, McConnell said that he had spoken with McCain on Monday morning and that “he’ll be back with us soon.” The Arizonan is recovering from surgery to remove a blood clot above his left eye that involved opening his skull.

McConnell had delayed action on the health-care bill until ­McCain’s return in hopes that he could be persuaded to vote yes. That hope faded after Lee’s and Moran’s announcements, however, with McCain issuing a statement from Arizona calling for a fresh, bipartisan start.

Senate Republicans have been under self-imposed pressure to complete their work on health care. As they have struggled to show progress, McConnell has said he would keep the chamber in session through the first two weeks of August, postponing the start of the summer recess period to leave time to work on other matters.

Kelsey Snell, Mike DeBonis and Ed O’Keefe contributed to this report.

GOP Healthcare Bill Written For Everyone Except Themselves: They Keep Golden Plan We Have To Pay For

(THIS ARTICLE IS COURTESY OF THE WASHINGTON POST)

New GOP health care bill will determine winners, losers

 July 15 at 2:36 AM
WASHINGTON — Republicans’ latest health care plan would create winners and losers among Americans up and down the income ladder, and across age groups.It would give consumers more responsibility for their insurance choices, a goal long held by conservatives who argue that’s key to a true health care market. Younger adults and healthy people in the solid middle class may find more agreeable options. But low-income people may not be able to afford coverage, along with older and sicker adults.

And there are potential unintended consequences for people with employer-provided insurance, currently about 170 million Americans. Allowing individuals to pay premiums from tax-sheltered accounts may create incentives for employers to stop offering coverage, say some independent analysts.

The legislation would put limits on federal spending for Medicaid, a partnership program with states to cover low-income people, the disabled and nursing home residents. The drawback is that state officials could eventually face no-win choices, such as having to pick between paying for coverage for low-wage working mothers and support services for elderly people trying to stay out of nursing homes.

As Senate Majority Leader Mitch McConnell, R-Ky., steers toward debate and votes next week, here is a look at some of the latest changes and major issues:

___

CRUZ’S PLAN

The new Senate bill incorporates the core of a proposal from Sen. Ted Cruz, R-Texas, that would reorganize the market for policies purchased by individuals. As many as 20 million Americans get coverage this way, about half through subsidized markets like HealthCare.gov, created under former President Barack Obama.

Cruz would change basic requirements that Obama’s law imposed on individual plans, including standard benefits such as pregnancy, maternity and newborn care; wellness visits and mental health treatment. The law also requires the same premium rates for sick and healthy people.

Under the Cruz approach, an insurer can offer plans that don’t comply with such requirements, provided they also offer coverage that does. The problem, say critics, is that the healthy would flock to low-premium, skimpy plans, leaving the sick to face escalating prices for comprehensive coverage.

“Healthy people would have opportunities to buy lower-premium, skinnier plans, while people with pre-existing conditions not eligible for premium subsidies could find themselves priced out of insurance,” said Larry Levitt of the nonpartisan Kaiser Family Foundation.

The latest bill includes another $70 billion to help states keep health insurance affordable for older, sicker customers. But it’s not clear how those backstops would work, and the federal funding eventually would end.

Some insurers are worried because of a technical change with huge practical implications: Health plans that enroll healthier customers would no longer have to cross-subsidize those with sicker patients, as is currently required.

“We think it is unworkable,” said Justine Handelman, top Washington lobbyist for the BlueCross BlueShield Association. She predicted skyrocketing costs for taxpayers also, stuck with the bill for sicker patients.

___

EMPLOYER ESCAPE HATCH?

McConnell’s new bill made a major change to tax-sheltered health savings accounts, which was also advocated by Cruz.

Under the bill, health savings accounts could be used to pay premiums with pre-tax money. Under current law, they can only be used to cover out-of-pocket costs, such as deductibles and copayments.

The change is meant to level the playing field for people buying individual plans, as compared to people getting employer coverage. The value of workplace insurance is tax-free for employees and tax-deductible for employers.

But some analysts say McConnell risks undermining workplace coverage.

The upside is that the change might encourage more self-employed people to buy individual health insurance policies. The downside is that some employers may see it as an invitation to drop health benefits, particularly since the GOP also would repeal Obama’s requirement that larger companies provide health care or face fines.

“Allowing individuals to purchase insurance with pre-tax dollars eliminates one of the advantages to employer-provided insurance,” said Elizabeth Carpenter of the Avalere Health consulting firm. “That may lead some employers to consider whether or not they want to continue to offer health insurance.”

___

THE POOR AND THE SICK

McConnell kept some of the Obama-era tax increases used by Democrats to finance expanded coverage. But the money will be going to shore up private insurance, not the Medicaid program. Medicaid accounts for half or more of the 20 million Americans gaining coverage as a result of the Affordable Care Act.

Medicaid covers low-income people, from many pregnant women and newborns, to disabled people and many elderly nursing home residents. The GOP bill would start by phasing out enhanced federal financing for Obama’s Medicaid expansion, adopted by 31 states. Perhaps more significantly, it would limit future federal funding for the overall program. As a result, it’s estimated Medicaid would cover 15 million fewer people by 2026.

The bill would add $45 billion to help states confronting the opioid epidemic pay for treatment and recovery. But that hasn’t swayed the American Medical Association, which points out that people in recovery also need comprehensive health insurance.

Republican governors don’t like the Medicaid cuts, and some have been vocal. About half the states that expanded Medicaid now have GOP chief executives.

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Nevada Gov. Brian Sandoval, a Republican who oversaw a Medicaid expansion, said more than 200,000 people gained coverage in his state.

“You think about 210,000 men, women and children, senior citizens, the drug addicted, the chronically ill,” Sandoval said. “These are people that used to get their treatment in emergency rooms, if they got any treatment at all. I keep going back to the fact that they are living a better quality of life.”

___

Associated Press writer Jennifer McDermott in Providence, Rhode Island, contributed to this report.

Copyright 2017 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

What’s Inside Mitch McConnell’s Latest Health-Care Proposal

(THIS ARTICLE IS COURTESY OF THE ATLANTIC NEWS AGENCY)

What’s Inside Mitch McConnell’s Latest Health-Care Proposal

The revised Senate bill would keep more of Obamacare’s taxes while allowing insurers to wiggle out of its regulations. Will Republicans go for it?

J. Scott Applewhite / AP

revised Senate health-care bill

Seeking to quell a revolt from more than one-fifth of his conference, Majority Leader Mitch McConnell agreed to forego two significant tax cuts for the wealthy and instead pour hundreds of billions of dollars back into the proposal he released two weeks ago. There’s now $45 billion to combat opioid addiction and even more funding to help mitigate higher insurance costs for low-income people and to stabilize the individual markets. An additional $70 billion would go to states to help drive down premiums, on top of $112 billion that was in the original proposal. McConnell’s target was senators toward the center of the Republican ranks, who represented the largest bloc of opposition to his first legislative draft.To woo conservative critics, the majority leader added a provision based on a proposed amendment from Senators Ted Cruz of Texas and Mike Lee of Utah—backed by pressure from a number of activist groups—that would allow insurance companies to sell stripped-down, inexpensive plans that don’t conform to Obamacare’s standards as long as they offer at least one policy that does. Well, sort of. McConnell’s draft includes the Cruz-Lee idea in brackets, an indication of its polarizing and therefore precarious status within the GOP health-care debate.

McConnell needs to pick up support from both ends of the ideological spectrum. He can afford only two Republican defections, and at least 10 of his members had come out against the first version of the Better Care Reconciliation Act before McConnell abandoned plans to bring it up for a vote last month. Two of those critics, Senator Susan Collins of Maine in the center and Senator Rand Paul of Kentucky on the right, appear to have hardened in their opposition this week. Collins said it would take “a complete overhaul” to win her support, and Paul has gone on a media tour to rail against the revised proposal, saying that based on what he had heard, it was even worse than the original because it repealed less of Obamacare and included a bigger “bailout” for insurers.

Within hours after the revised draft’s release, both Paul and Collins reiterated their opposition to it an d said they would vote against even bringing it up for debate. As on the final vote, McConnell needs at least 50 Republicans to sign off on the procedural motion, and with Paul and Collins apparently out, he needs every other member of his conference to agree.

In a speech on the Senate floor after unveiling the bill to Republicans, McConnell pleaded with his colleagues to allow it at least to come up for debate. “I hope every senator will vote to open debate. Because that’s how you change the status quo,” he said. “This is our opportunity to really make a difference on health care. This is our chance to bring about changes we’ve been talking about since Obamacare was forced on the American people. It’s our time to finally build the bridge away from Obamacare’s failures and deliver relief to those who need it.”While McConnell picked quick support from several party loyalists, most of the holdouts on the original draft remained undecided. Senators Rob Portman of Ohio and Shelley Moore Capito of West Virginia said they would review the bill, as did Senator Dean Heller of Nevada, a sharp critic initially who is under intense pressure in the run-up to a reelection campaign next year. In an ominous sign for McConnell, however, Capito said in a statement she still had “serious concerns” about the proposal.

McConnell all but ignored complaints from moderates to soften the bill’s deepest and most contentious cuts—a $772 billion reduction in Medicaid spending over a decade, with hundreds of billions in additional cuts in the 10 years after that. The cuts, which include a four-year phase-out of Obamacare’s Medicaid expansion and a change in the program’s growth rate, would not begin until 2020. According to the Washington Post, McConnell told moderates to support the bill with those cuts included because they would never go into effect.

Though rather cynical, it’s an assumption held by some in Washington-based on the likelihood that Democrats will win control of the House in 2018 or the presidency in 2020 and work with Republicans to put off the Medicaid cuts.While the new bill maintains most of the Medicaid cuts, it changes the formula under which hospitals would be reimbursed for treating patients that can’t pay their bill. And it would allow states some wiggle room if a public health emergency was declared or to seek a waiver to access more funds to cover the elderly and disabled, according to a summary posted by the Senate Budget Committee.

Yet like the entire bill itself, McConnell’s Medicaid bet is a risky one. Senators like Collins, Lisa Murkowski of Alaska, Heller, Portman, and Capito have strongly opposed the cuts to Medicaid and were already frustrated with the secretive, top-down process McConnell has led on the health-care bill. And conservative activists and senators have pointed to the Medicaid changes as one of the few things they like about a proposal that does not truly fulfill their promise to repeal Obamacare. They had already stomached the Senate’s longer lead-time in ending the ACA’s Medicaid expansion, but will they recoil at McConnell’s reported admission that the reforms might not endure at all?

In another blow to Collins and Murkowski, McConnell also retains provisions blocking federal funds from going to Planned Parenthood and banning the use of subsidies to purchase plans that cover abortion. Both senators had criticized those aspects of the original bill, and if both Collins and Paul vote against the legislation as they’ve indicated, Murkowski’s opposition on those grounds could sink it entirely.

Cruz has demanded the inclusion of his Consumer Freedom Choice Amendment in the underlying Senate bill as the price for his support. But the version that McConnell included was different, Lee tweeted shortly before Republicans were scheduled to see the revised bill for the first time.

Just FYI – The Cruz-Lee Amendment has not been added to BCRA. Something based on it has, but I have not seen it or agreed to it. 1/2

9:52 AM – 13 Jul 2017

I am withholding judgment and look forward to reading it. 2/2

While Lee was undecided, Cruz told reporters that he would support the bill as long as his amendment stayed in and no other changes were made. His position appeared to mimic the new stance of conservative activist groups, who have conceded that Republicans can’t fully repeal the Affordable Care Act but in recent days made the adoption of Cruz’s amendment striking at its core regulations their final demand. Even Grover Norquist, the anti-tax activist who has prioritized the repeal of Obamacare’s tax increases, issued a statement signaling he was okay with McConnell’s decision to keep some of them now as long as the leadership committed to getting rid of them in subsequent tax-reform legislation. Norquist told me in an interview last month that keeping the taxes on the wealthy even temporarily was “a bad idea.”

Illustrating McConnell’s challenge in navigating the bill to passage, the changes that Cruz and Lee are demanding could solidify opposition among moderates or lose even more votes among Republicans leery of doing anything that threatens protections for people with preexisting conditions. The health-care industry is aligned against the proposal, which would essentially create separate insurance markets for sick and healthy people. Even the insurance industry’s top lobbying group, America’s Health Insurance Plans, came out in public opposition to the amendment after staying quiet through much of the Senate debate. Whether the Cruz amendment stays in the bill is in doubt. A senior GOP policy staffer said Thursday the provision was put in brackets in the bill text because “the policy is continuing to be worked on as members react to it.” Republicans have asked the Congressional Budget Office to score versions of the bill with and without the Cruz policy, but it’s unclear whether the report released next week will fully assess the amendment.

The next big test for McConnell will come early next week, when the CBO releases its analysis. The original bill fared little better with the CBO than the legislation House Republicans passed in May; the budget office found that the Senate bill would result in 22 million fewer people having health insurance after a decade. McConnell is hoping that the infusion of money into the subsidy and stabilization programs will improve that number and boost support for the bill. But if three or Republicans vote against a procedural motion to bring the proposal to the floor next week, it won’t even see a formal debate.In an indication of how dicey the revised bill’s prospects were, two Republican senators, Lindsey Graham of South Carolina and Bill Cassidy of Louisiana, chose the day of its release to unveil their own, competing idea for a partial replacement of Obamacare. Appearing on CNN before a crucial GOP meeting, they proposed a plan that would do away with Obamacare’s individual and employer mandates but keep most of its tax increases. But instead of funding a federal subsidy program, that revenue would be sent to the states so that they could craft their own health-care plans as they saw fit.

“If you like Obamacare and you want to repair it, you can,” Graham said on CNN. “If you want to replace it, you can.”

The idea is in line with an earlier proposal from Cassidy and Collins that would have allowed states to choose whether they kept Obamacare or not. That plan went nowhere, but with Republicans nearing a stalemate on health care, the senators are betting that their colleagues will give it another look.

New GOP health care bill could allow cheaper plans with fewer benefits

(THIS ARTICLE IS COURTESY OF CNN)

New GOP health care bill could allow cheaper plans with fewer benefits

  • Cruz’s so-called Consumer Freedom amendment is contentious among Republicans
  • The amendment would allow insurers to sell cheaper plans with fewer benefits

Washington (CNN) Senate Republicans unveiled their newest health care bill Thursday as they continue to search for the majority needed to repeal and replace Obamacare.

Now, it’s up to senators to decide if they like it.
The new bill includes major changes to the original. One of the most significant was the inclusion of an amendment by Texas Sen. Ted Cruz, which would allow insurers offering Obamacare plans to also offer cheaper, bare-bones policies. The amendment was included in an effort to earn more conservative support, but could also drive away some moderates who fear the amendment could drive up premiums for those with pre-existing conditions.
It also contains significant new funding for opioid treatment and money for states meant to lower premiums for high-cost enrollees. But it would keep two Obamacare-era taxes on the wealthy and maintains significant cuts to Medicaid, meaning 15 million fewer people could insured by the program by 2026.
Majority Leader Mitch McConnell is still in search of the 50 votes he needs to pass the bill — he can only afford to lose two senators — but the hope for leadership is that a few changes may be able to finally get Republicans on a path to repeal and replace Obamacare after seven years of campaign promises.
Already on Thursday Sen. Rand Paul of Kentucky said he wouldn’t even support the motion to debate the bill on the floor.
Sen. Susan Collins, a Republican from Maine, also told reporters that she would not vote for the motion to proceed unless she saw significant signs from the nonpartisan scoring agency — the Congressional Budget Office — that the cuts to Medicaid would be less severe than she anticipated.
“The only thing that can change that is if the CBO announcement, which come out on Monday, indicates that there would be far fewer in Medicaid than I believe there are now,” Collins said.
Emerging from a meeting with fellow senators Thursday, Republicans were cautiously optimistic with many saying they needed to sit down to read the bill before they made any final decisions.
Sen. Jeff Flake, an Arizona Republican, said he was “still thinking” as reporters swarmed him.
Sen. Bill Cassidy of Louisiana said “I always want to say I criticized Nancy Pelosi for saying ‘we got to pass the bill to know what’s in it.’ I want to know what’s in it before I say I’m gonna pass the bill.”
Moderates from Medicaid expansion states continued to voice their concerns about the new bill. West Virginia Republican Sen. Shelley Moore Capito said she was “very much undecided” and would meet once again with McConnell this afternoon.
“I still think there’s a lot of unanswered questions particularly coming from a state that has a high percent of people with pre-exiting conditions,” she said.
Alaska Sen. Lisa Murkowski, one of the GOP holdouts, was unhappy that reporters had seen a summary distributed to lobbyists before she had seen the bill.
Asked if she was upset by how the process unfolded, she said “yes.”
“I think that as a courtesy to those of us who are actually making the decisions that we would actually have an opportunity to see it first,” Murkowski added.
A major question remains whether President Donald Trump can use his bully pulpit to actually move senators.
Trump has lobbied for Republicans to move quickly. The President said Wednesday he would be “very angry” if Republicans can’t pass the bill.
“I don’t even want to talk about it because I think it would be very bad,” Trump said in an interview with the Christian Broadcasting Network. “I will be very angry about it and a lot of people will be very upset.”

What’s new?

The revised legislation has $45 billion in opioid treatment funding — a top request from senators like Rob Portman of Ohio and Shelley Moore Capito of West Virginia — as well as in state stabilization money aimed at lowering premiums for high-cost enrollees.
But another concern for moderate senators — that the Senate bill makes steep cuts to Medicaid funding — was not addressed in the new version. The original bill calls for slashing $772 billion from Medicaid by 2026, compared to current law, leaving 15 million fewer people insured by the program.
In a retreat from a key GOP promise, the bill would also keep two Obamacare-era taxes on the wealthy. That came as members said they worried about the optics of cutting taxes for the rich while also slashing funding for subsidies that go to help low-income people to buy insurance. Retaining the taxes, which saves the federal government $230 billion over 10 years, provides McConnell money to help boost the stabilization fund, sources said. But it is also likely to infuriate conservative lawmakers and lobbying groups.
The legislation would allow consumers to use their health savings accounts to pay their premiums for the first time, which Cruz called “very significant.”

Graham plan

Also Thursday, GOP Sens. Cassidy and Lindsey Graham of South Carolina proposed an alternative approach to replacing Obamacare that would keep much of the federal taxes in place and sending that money to the states to control.
They say that one of the primary reasons Republicans are having such a hard time agreeing is because they are working from the Obamacare template — particularly federal control of health insurance.

Cruz amendment

Cruz’s so-called Consumer Freedom amendment is considered contentious among Republican senators with some moderates having raised concerns that it could hurt those with pre-existing conditions. The amendment would allow insurers that offer Obamacare plans on the exchanges to also sell policies that are exempt from certain of the law’s mandates. That could allow carriers to provide less comprehensive plans with lower premiums, which would likely attract younger and healthier Americans.
But that would leave the sicker, more expensive consumers in the Obamacare plans, causing their premiums to spike.
Offering Obamacare plans will also make insurers eligible for new federal funding aimed at helping insurers pay for high-cost enrollees.
Sen. Mike Lee — a Utah Republican and close Cruz ally — tweeted Thursday morning to say that he has not seen the newest version of the Cruz amendment included in leadership’s health care bill and was unsure if he could support it.
There’s also no guarantee the Cruz amendment — in whatever form — will even get a Senate vote. It could be stripped from bill at any time as GOP leaders negotiate and work their way through Senate rules.
Insurers, who have largely stayed on the sideline in the health care debate, voiced strong opposition to the amendment, saying it would destabilize the individual market. Two major lobbying groups said this week that it would create two sets of rules and make coverage unaffordable to those who are sick.
“I’m writing to make clear my view on how the ‘Consumer Freedom Option’ is unworkable as it would undermine pre-existing condition protections, increase premiums and destabilize the market,” Scott Serota, CEO of Association of Independent Blue Cross Blue Shield Plans, wrote to Senators Cruz and Lee earlier this week.

Republican Heath Care Bill: Senator Mitch McConnell No Longer Strutting Like A Bird Fed Cat

(THIS ARTICLE IS COURTESY OF CNN)

Just because it was the weekend leading into the Independence Day holiday doesn’t mean there weren’t developments for Republicans’ plans to repeal and replace the Affordable Care Act. Here’s what you might have missed:

Despite tweets on Friday from President Donald Trump and several high-profile Republican senators, the “repeal, then replace later” option is not really on the table and isn’t something that will be pursued by GOP leadership as they try to pull together the 50 votes they need to pass their health care plan. Negotiations are continuing as planned for a proposal that repeals and replaces Obamacare simultaneously.
As CNN reported Friday, there is almost no chance senators will vote on a health care bill the week senators return from recess. Expect the health care negotiations to be a multi-week process.
Senate Majority Leader Mitch McConnell is sending several different proposals and basic outlines to the Congressional Budget Office to help speed up the final scoring process, as CNN reported several times last week. Although the top White House legislative official, Marc Short, said Sunday on Fox News that McConnell sent two bills to CBO for scoring; that’s not exactly the case. McConnell actually sent two outlines, plus several other proposals that may make it into a final bill.
The future of the proposal continues to depend on whether there is some compromise resolution on the same issues, including a softer landing for the eventual Medicaid reforms and how to craft some acceptable version of Texas Sen. Ted Cruz’s regulations amendment into the final proposal. In his comments Sunday, Short appeared to give the White House endorsement to Cruz’s regulations proposal, which if so would be no small thing.
Opioid funding and changes to regulations related to the use of health savings accounts appear to be settled and locked in.
A still looming, very real fight that will be coming when they return: whether to repeal the 3.8% investment tax in Obamacare or not. This is not at all settled, but sources tell CNN this is something that won’t be dealt with until Congress returns to Washington.

Republican Senator Sasse on health care: If no agreement, ‘repeal with a delay,’ then replace

(THIS ARTICLE IS COURTESY OF CNN)

Republican Senator Sasse on health care: If no agreement, ‘repeal with a delay,’ then replace

Story highlights

  • Sasse first suggested the option in a letter to President Donald Trump on Thursday
  • Mitch McConnell said he will stick to the path of trying to accomplish both simultaneously

(CNN) Nebraska Sen. Ben Sasse on Sunday clarified his suggestion that lawmakers “repeal and then replace” Obamacare, saying if Republicans can’t agree on a replacement plan in the next week or so, they should repeal the law “with a delay” and then agree on a replacement plan later.

“If Leader McConnell can get us across the finish line in a combined repeal and replace, I’d like to see that happen,” the Republican freshman senator said in an interview with Jake Tapper on CNN’s “State of the Union.” “It needs to be a good replace, but if we can do a combined repeal and replace over the next week that’s great. If we can’t, though, then there’s no reason to walk away. We should do repeal with a delay — let’s be clear, I don’t want to see anybody thrown off the coverage they have now. I would want to delay so that we can get straight to work.”
Sasse first suggested the option of repealing and then replacing Obamacare in a letter to President Donald Trump on Thursday — an idea that Trump also voiced, but was met by criticism from both Republicans and Democrats who worried that it could harm Americans by leaving them without coverage.
“On July 10, if we don’t have agreement on a combined repeal and replace plan, we should immediately vote again on H.R. 3762, the December 2015 ObamaCare repeal legislation that the Congress passed but President Obama vetoed,” Sasse wrote in the letter. “We should include a year-long implementation delay to give comfort to Americans currently on ObamaCare that a replacement plan will be enacted before expiration.”
Later that day, Trump tweeted, “If Republican Senators are unable to pass what they are working on now, they should immediately REPEAL, and then REPLACE at a later date!”
Republican Rep. Adam Kinzinger of Illinois rejected the suggestion of repealing and then later replacing the law, saying it could harm Americans.
“I think it’s repeal and replace,” Kinzinger told CNN’s Chris Cuomo Friday on “New Day.” “We can argue whether they like the system we’re bringing them in or not, but simply a repeal, even with the sunset the year or two down the road — the problem (is) we know how Washington works.”
The current Republican plan in Congress is to do both a repeal and a replacement of the law in one massive piece of legislation, though the Senate’s bill has struggled to gain the necessary GOP support.
“I think we need to do both repeal and replace, and I’m a little agnostic as to whether they’re paired or separated,” Sasse added in his “State of the Union” interview on Sunday, calling for the cancellation of the Senate’s August recess so lawmakers can get to work on a replacement plan.
Senate Majority Leader Mitch McConnell said Friday that he will stick to the path of accomplishing both a repeal and a replacement together.
Finding a replacement for the law is “very challenging,” but allowing Obamacare to remain in place is not an option, McConnell said, according to a video of his remarks posted on the website of the Courier-Journal newspaper, based in Louisville, Kentucky.

Abortion Adds Obstacle as Republicans Plan to Unveil Health Bill

(THIS ARTICLE IS COURTESY OF THE NEW YORK TIMES)

Senator Mitch McConnell of Kentucky, the majority leader, hopes to unveil the contents of Republicans’ health bill on Thursday and pass it next week. CreditDoug Mills/The New York Times

WASHINGTON — Abortion flared up Wednesday as the latest hot-button issue to complicate passage of a bill to repeal and replace the Affordable Care Act, which Senate Republican leaders hope to unveil on Thursday and pass next week.

The repeal bill approved last month by the House would bar the use of federal tax credits to help purchase insurance plans that include coverage of abortion. But senators said that provision might have to be jettisoned from their version because of complicated Senate rules that Republicans are using to expedite passage of the bill and avoid a filibuster.

If that provision is dropped, a bill that has already elicited deep misgivings among moderate Republicans — and stiff resistance from Democrats, health care providers and patient advocacy groups — could also generate concern among abortion opponents, as well as conservative lawmakers.

Further complicating the measure’s prospects, insurance companies, which took a leading role in the health care fights of 1993-94 and 2009-10 but have been conspicuously quiet this year, released a blistering letter objecting to Republican plans to remake Medicaid and cut its funding.

Continue reading the main story

The changes being considered in Congress could “amount to a 25 percent shortfall in covering the actual cost of providing care to our nation’s neediest citizens,” the top executives of 10 insurance companies wrote this week. “These amounts spell deep cuts, not state flexibility, in Medicaid.”

As senators struggle to develop a health care bill, their handiwork appears to be too moderate for some Senate conservatives and too conservative for some Senate moderates. The latest version, without the abortion-coverage prohibition and with steep Medicaid cuts, may prove unacceptable to some in both camps. To pass it, Senate leaders can afford to lose only two Republican votes of the 52 in the chamber.

Republican senators got a glimpse Wednesday of the highlights of the bill, which was drafted in secret by the majority leader, Senator Mitch McConnell of Kentucky, and top aides. White House officials were granted a formal briefing, which risked irking many senators who had yet to see the actual bill.

The House abortion provision has sweeping implications because many health plans subsidized under the Affordable Care Act include coverage for abortion services. The provision has encountered outspoken opposition from officials in states like Oregon, where most health plans on the public insurance exchange cover abortion.

But senators said the provision might have to be dropped for a more prosaic reason: It may not comply with the Senate rules that Republicans are using to speed the health care bill through the Senate.

The bill is scheduled to go to the Senate floor next week under these procedures, which limit debate and preclude a Democratic filibuster.

“It’s one of the problems we have to work with,” Senator Orrin G. Hatch, Republican of Utah and the chairman of the Finance Committee, said of the abortion issue. “We’re not quite sure how that’s going to be resolved.”

Mr. McConnell is determined to get a vote on the bill by the end of next week, before a break for the Fourth of July holiday, but he still does not have enough committed votes to ensure passage.

Senator Rand Paul, Republican of Kentucky, made clear on Wednesday that he was not on board with the Republican bill.

“I’m still hoping we reach impasse, and we actually go back to the idea we originally started with, which is repealing Obamacare,” Mr. Paul said, adding, “I’m not for replacing Obamacare with Obamacare lite.”

Document: Health Insurers Speak Out

The House bill and the Senate version, like the Affordable Care Act, would provide tens of billions of dollars in tax credits to help people pay insurance premiums.

The federal government is expected to spend more than $30 billion this year on tax credits to help lower- and middle-income people pay premiums. The Senate bill would provide more assistance to lower-income people than the House bill, which bases tax credits on a person’s age.

The Senate bill would also repeal most of the taxes imposed by the Affordable Care Act. It would delay the effective date of a tax on high-cost employer-sponsored health coverage, but Republicans plan to offer an amendment next week to eliminate this “Cadillac tax,” which is opposed by labor unions and employers.

Senators Thom Tillis of North Carolina and Susan Collins of Maine, both Republicans, said they understood that the House restrictions on the use of tax credits for insurance covering abortion had encountered parliamentary problems.

“What I heard earlier from the parliamentarian is they didn’t think it would pass” muster under Senate rules, Mr. Tillis said.

Mr. Tillis and Ms. Collins said they understood that Senate Republican leaders were hoping to devise some kind of workaround to address concerns of anti-abortion lawmakers. But it was not clear whether those anti-abortion lawmakers would be satisfied with such a plan, which could involve separate legislation.

Republicans have been promising to repeal the health law ever since it was signed by President Barack Obama in 2010. On Wednesday, in the final hours before the Senate repeal bill was to be unveiled, members of Congress, consumer groups and health care executives engaged in frenetic advocacy in hopes of shaping the bill.

Women’s groups and at least two moderate Republicans, Ms. Collins and Senator Lisa Murkowski of Alaska, continued to object to a provision of Mr. McConnell’s bill that would cut off funds for Planned Parenthood.

In a letter to Mr. McConnell on Wednesday, more than two dozen House members in the conservative Republican Study Committee listed several parts of the House bill they view as crucial, including cutting funds to Planned Parenthood and restricting the use of the tax credits. The bill, they wrote, fulfills “an important conservative commitment to promote life and protect the unborn.”

Leaders of the 10 insurance companies told Mr. McConnell that proposed caps on federal Medicaid spending would cause “an enormous cost shift to the states,” which could force them to raise taxes, reduce benefits, cut payments to health care providers or eliminate coverage for some beneficiaries. Among those signing the letter were top executives of AmeriHealth Caritas, Molina Healthcare, Blue Shield of California and Healthfirst, in New York.

But Senator John Kennedy, Republican of Louisiana, said the Medicaid provisions were one of the bill’s chief attractions for him.

“In my state,” Mr. Kennedy said, “we are now spending 47 percent of our budget on Medicaid. That’s up from 23 percent in 2008. It’s crowding out money for universities and roads and public safety and coastal restoration, and it just keeps climbing.”

Even senators who might support the legislation said they did not want to be rushed.

Asked how he felt about the prospect of voting for a bill a week after its release, Senator John McCain, Republican of Arizona, said, “I feel terrible about it.”

12COMMENTS

Senator Ron Johnson, Republican of Wisconsin, said, “I need the information, I need to hear from constituents, and that’s going to take some time.”

Debate on the Senate bill will be shaped by an analysis from the Congressional Budget Office, which will estimate the impact on federal spending and the number of people without health insurance. Under the House bill, the office said, the number of uninsured would be 23 million higher than under the Affordable Care Act in 2026. And for some older Americans and sick people, it said, premiums and out-of-pocket costs could be significantly higher.

Senate Leader Mitch McConnell Proving He Cares Nothing About The Voters, Only Doners

(THIS ARTICLE IS COURTESY OF THE WASHINGTON POST)

Politics

Senate leaders plan to rush a health-care bill to a vote, and there’s nothing Democrats can do about it

June 19 at 1:11 PM

When the Republican-led Senate Rules Committee briefly flirted with the idea of restricting television interviews in the hallways of the Capitol last week, it became only the most obvious manifestation of how the party’s leaders were handling the development of a bill to overhaul Obamacare: out of the public eye.

While that effort was quickly sidelined after some outcry, the Republican leadership in the Senate was otherwise unfazed in its push to craft a bill that would expose its members to as little negative public attention as possible. No repeat of the town hall meetings that drew angry constituents who yelled at House Republicans and, they clearly hope, no weeks and weeks of swamped office phone lines.

In an article for the Monkey Cage, George Washington University’s Sarah Binder explained the four ways in which the Senate effort was unusually secretive. Sure, members of Congress would always rather pass legislation without dealing with negative criticism, but rarely have they gone so dark on such a big effort.

Here’s what’s in the new CBO report on the Republican health-care bill
The Congressional Budget Office has released its score on the revised American Health Care Act. Here’s what’s in the report. (Daron Taylor/The Washington Post)

The question that arises, though, is what Democrats could actually do about it. Binder told me that the answer was probably a simple one.

Nothing.

“I have a hard time seeing a real avenue for successful obstruction by the Democrats,” Binder said. The situation is unusual enough that making hard and fast predictions is tricky, she said, but “Republicans have been so aggressive on procedure here that I’d expect them to … get this through without any heed of what the Democrats were raising.”

In particular, Binder addressed a proposal outlined in a series of tweets last week by Ezra Levin, a former deputy policy director for House Democrats. Levin suggested that the Democrats could introduce an almost infinite number of amendments that would choke the Senate calendar indefinitely until they got what they wanted.

The plan hinges on the way in which the bill is being moved through the Senate. To avoid the need for Democratic votes — which the Republican majority wouldn’t get — the Obamacare replacement is being advanced using what’s known as the reconciliation process. That process involves a special set of rules that are meant to fast-track debate over the budget, but, given that it also means legislation can avoid a filibuster in the Senate, it has also been used to pass controversial bills. (Several fixes essential to the passage of Obamacare were moved using the reconciliation process, for example.)

Those rules, defined by law, include allowing only 20 hours for debate but it also includes a process called “vote-a-rama,” in which amendments may be proposed and must be voted on before the final passage of the bill. That’s where Levin’s idea comes in: He proposed introducing tens of thousands of amendments that would need to be voted on before the Senate’s bill could be passed. In theory, Levin figured, Democrats could introduce enough amendments to shut down the Senate for a year.

Binder disagrees.

“In reality, that’s not going to happen,” she said. What was more likely, she said, is that someone would make a point of order that the Democrats were being “dilatory” — that is, slowing down the process unnecessarily. The presiding officer — the Republican senator on duty to manage floor debate — would be asked to rule on whether that was the case and would likely agree. Democrats could appeal the decision, but a majority vote would end the process.

Senate returns more pessimistic than ever on healthcare

(THIS ARTICLE IS COURTESY OF THE HILL NEWSPAPER)

Senate returns more pessimistic than ever on healthcare

Senators went into a recess skeptical over whether they could agree to legislation repealing and replacing ObamaCare.

They will return on Monday more doubtful than ever.

Sen. Richard Burr (R-N.C.), one of Senate Majority Leader Mitch McConnell’s (R-Ky.) most loyal allies, said Thursday that it’s “unlikely” the GOP will get a healthcare deal.

“I don’t see a comprehensive healthcare plan this year,” he told a local news station.

Senate Republicans hoped to have a draft bill this week, but it now looks like there will at best be an outline.

A Senate Republican aide said it’s too early to begin drafting legislation that can come to the floor in the next few weeks.“Parameters are more likely,” said the aide, who explained that McConnell wants to keep the details held closely so the legislation doesn’t get picked apart before lawmakers have a chance to consider it carefully.

“The last thing we want to do is litigate this in the press,” the aide said. “We want to discuss parameters and concepts without releasing a draft.”

“Maybe they can start talking to members about a specific product next week, but I would not be surprised if we don’t,” said another Senate GOP aide.

More unhelpful news came in the form of a Kaiser Family Foundation poll underscoring how unpopular the bill approved by the House is.

It found that three-quarters of Americans surveyed think the House bill does not fulfill President Trump’s promises on healthcare.

A full 82 percent said federal funding for ObamaCare’s expansion of Medicaid should be continued, an issue that deeply divides the Senate GOP. The House bill ends the ObamaCare funds in 2020.

Yet another factor for Republicans is Trump’s approval rating, which has fallen to its lowest point with Republicans since he took office in the latest Reuters/Ipsos tracking poll.

Republicans already had sought to lower expectations.

McConnell conceded last week that, “I don’t know how we get to 50 [votes] at the moment.”

He sounded more optimistic about passing major tax reform legislation, rating its chances as “pretty good.”

Republicans control 52 seats and can afford only two defections from their ranks. Vice President Pence could cast the deciding vote in case of a 50-50 tie.

The Senate GOP hasn’t given up hope on healthcare and faces tremendous pressure from the White House and House Republicans to hold a vote.

Republicans for years have promised to repeal ObamaCare, so failure would be a major blow. They also face pressure to finish their work on healthcare because of the tax reform push.

The GOP is using special budgetary rules to prevent Democrats from filibustering legislation on tax reform and healthcare.

Republicans can’t move to tax reform until the healthcare debate is finished because once they pass a new budget resolution that would allow them to move tax legislation with 51 votes, they will lose the vehicle set up to enable a healthcare bill that would circumvent a Democratic filibuster.

Those on a special 13-member working group have heard very little about the drafting efforts that were supposed to take place over the recess.

Senate Budget Committee Chairman Mike Enzi (R-Wyo.) was to provide the framework in consultation with GOP leaders and Senate Finance Committee Chairman Orrin Hatch (R-Utah).

A major sticking point in the Senate is Medicaid. The House bill would cut nearly $900 billion from the program and cap the federal contribution for expanded enrollment in that program by 2020.

Several Republican governors from Medicaid expansion states, led by Govs. John Kasich (Ohio) and Rick Snyder (Mich.), earlier this year came out against the House bill, warning that it failed to provide adequate resources.

Sen. Rob Portman (R-Ohio) said he wants a more gradual “glide path” for capping the expansion, an idea not popular with conservatives.

Twenty Republican senators, including Portman, represent states that opted to expand Medicaid, and many of them worry that cutting federal funding will cause significant budget problems at home.

But another group of GOP governors, primarily from states that opted out of the Medicaid expansion, want to end federal support for the expansion.

Senators are divided as well over proposals to limit federal assistance for health insurance subsidies, which would hit older, low-income Americans disproportionately.

McConnell hasn’t set a deadline for passing the ObamaCare repeal-and-replace bill, but he has indicated concern about the debate dragging on for months, which could imperil tax reform.

“We can’t take forever,” he told Bloomberg TV last month.

By raising doubts about the possibility of getting a deal that musters 51 votes, the GOP leader is putting pressure on his colleagues to either come together or move on before the August recess.

McConnell has told colleagues that the 13-member working group will put together a bill and that he will bring it to the floor for a vote, but he has stopped short of promising that it will pass — in contrast to Speaker Paul Ryan (R-Wis.), who earlier this year guaranteed that the House bill would pass.

If the Senate bill fails on the floor, McConnell is likely to declare the GOP conference has worked its will and move on.

Even as the House voted to narrowly pass the House’s American Health Care Act last month, there was already strong pessimism among Senate Republicans about the chances of putting together a comprehensive package in the upper chamber.

A senior GOP senator at the time said the chances of getting 51 votes for legislation based on the House healthcare bill were less than 1 in 5.

When House Republicans debated healthcare reform earlier this year, some of their Senate colleagues said privately that they thought it might be better if the legislation died in the lower chamber.

G.O.P. Health Bill Would Leave 23 Million More Uninsured in a Decade, C.B.O. Says

(THIS ARTICLE IS COURTESY OF THE NEW YORK TIMES)

Protesters demonstrated outside the Capitol as Republican members of the House narrowly passed the health care bill this month. CreditGabriella Demczuk for The New York Times

WASHINGTON — A bill to dismantle the Affordable Care Act that narrowly passed the House this month would increase the projected number of people without health insurance by 14 million next year and by 23 million in 2026, the Congressional Budget Office said Wednesday. That 10-year figure is slightly less than originally estimated.

It would reduce the federal deficit by $119 billion over a decade, less than the $150 billion in savings projected in late March for an earlier version of the bill. And in states that seek waivers from rules mandating essential health coverage, the new law could make insurance economically out of reach for some sick consumers.

“Premiums would vary significantly according to health status and the types of benefits provided, and less healthy people would face extremely high premiums,” the budget office concluded.

GRAPHIC

New C.B.O. Score: G.O.P. Health Bill Would Save Government Billions but Leave Millions Uninsured

A look at crucial numbers in the Congressional Budget Office report.

OPEN GRAPHIC

The new forecast of the nonpartisan Congressional Budget Office, Capitol Hill’s official scorekeeper, is another blow to Republican efforts to undo President Barack Obama’s signature domestic achievement. The Senate has already said it will make substantial changes to the measure passed by the House, but even Senator Mitch McConnell of Kentucky, the majority leader, is sounding uncertain about his chances of finding a majority to repeal and replace the health law.

Continue reading the main story

“I don’t know how we get to 50 at the moment,” Mr. McConnell told Reuters on Wednesday. “But that’s the goal.”

The new report from the budget office is sure to influence Republican senators, who are writing their own version of the legislation behind closed doors. The report provided fresh ammunition for Democrats trying to kill the repeal bill, which they have derided as “Trumpcare.”

 

Video

How the GOP Health Plan Would Treat the Sick

Reporter Margot Sanger-Katz examines high-risk pools, the controversy at the heart of the health care debate.

By ROBIN STEIN, MARGOT SANGER-KATZ and SUSAN JOAN ARCHER on Publish DateMay 24, 2017. Photo by Brendan Smialowski/Agence France-Presse — Getty Images. Watch in Times Video »

Republicans in Congress generally focus more on reducing health costs than on expanding coverage. Their proposals will inevitably cover fewer people than the Affordable Care Act, they say, because they will not compel people to buy insurance.

Republicans have been trying to repeal Mr. Obama’s health law since the day he signed it in March 2010. But the task is proving more difficult than they expected. Many parts of the law have become embedded in the nation’s health care system, and consumers have risen up to defend it, now that they fear losing its protection. At the same time, other consumers, upset about the mandate to buy insurance they can barely afford, are demanding changes in the law.

The budget office issued two reports on earlier versions of the House bill in March. Both said that the legislation would increase the number of uninsured by 14 million next year and by 24 million within a decade, compared with the current law.

GRAPHIC

The Parts of the Affordable Care Act That the Republican Bill Will Keep or Discard

A comparison of the amended bill with key components of the Affordable Care Act.

OPEN GRAPHIC

Republican senators appear as determined as ever to replace the health law.

“The status quo under Obamacare is completely unacceptable and totally unsustainable,” Mr. McConnell said Wednesday, a few hours before the budget office issued its report. “Prices are skyrocketing, choice is plummeting, the marketplace is collapsing and countless more Americans will get hurt if we don’t act.”

“Beyond likely reiterating things we already know — like that fewer people will buy a product they don’t want when the government stops forcing them to — the updated report will allow the Senate procedurally to move forward in working to draft its own health care legislation,” he added.

The instability of the health law’s insurance marketplaces was underscored again on Wednesday when Blue Cross and Blue Shield of Kansas City, a nonprofit insurer, announced that it would not offer coverage under the law for 2018. The insurer lost more than $100 million in 2016 selling individual policies under the law, said Danette Wilson, the company’s chief executive.

Senator Chuck Schumer of New York, the minority leader, speaking to reporters in Washington on Tuesday.CreditAl Drago/The New York Times

“This is unsustainable,” she said in a statement. “We have a responsibility to our members and the greater community to remain stable and secure, and the uncertain direction of the market is a barrier to our continued participation.”

While the vast majority of people the company covers get insurance through an employer or a private Medicare plan, Blue Cross of Kansas City covers about 67,000 people in Kansas City and western Missouri under the federal health care law. The company’s departure could leave 25 counties in western Missouri without an insurer, said Cynthia Cox, a researcher at the Kaiser Family Foundation.

Democrats say much of that instability stems from Republican efforts to repeal and undermine the Affordable Care Act. The Senate minority leader, Chuck Schumer of New York, harshly criticized House Republicans for voting on their revised repeal measure without an updated analysis from the budget office.

“Republicans were haunted by the ghost of C.B.O. scores past, so they went ahead without one,” Mr. Schumer said. That action, he said, was reckless — “like test-driving a brand-new car three weeks after you’ve already signed on the dotted line and paid the dealer in full.”

The House repeal bill was approved on May 4 by a vote of 217 to 213, without support from any Democrats. It would eliminate tax penalties for people who go without health insurance and would roll back state-by-state expansions of Medicaid, which have provided coverage to millions of low-income people. And in place of government-subsidized insurance policies offered exclusively on the Affordable Care Act’s marketplaces, the bill would offer tax credits of $2,000 to $4,000 a year, depending on age.

A family could receive up to $14,000 a year in credits. The credits would be reduced for individuals making more than $75,000 a year and families making more than $150,000.

Senior Republican senators say they want to reconfigure the tax credits to provide more financial assistance to lower-income people and to older Americans, who could face much higher premiums under the House bill.

The House bill would roll back a number of insurance requirements in the Affordable Care Act, which Republicans say have driven up the cost of coverage.

In the weeks leading up to passage of the House bill, Republican leaders revised it to win support from some of the most conservative members of their party.

Under the House bill, states could opt out of certain provisions of the health care law, including one that requires insurers to provide a minimum set of health benefits and another that prohibits them from charging higher premiums based on a person’s health status.

Insurers would not be allowed to charge higher premiums to sick people unless a state had an alternative mechanism, like a high-risk pool or a reinsurance program, to help provide coverage for people with serious illnesses.

Senate Republican have been meeting several days a week, trying to thrash out their differences on complex questions of health policy and politics, like the future of Medicaid.

Asked why Democrats had been excluded, Mr. McConnell said, “We’re not going to waste our time talking to people that have no interest in fixing the problem.”

Democrats have said they would gladly work with Republicans if the Republicans would renounce their goal of repealing Mr. Obama’s health care law.

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