Senate Majority Leader Mitch McConnell (R-Kentucky) faces the challenge of bridging the gap between conservatives who want a full Obamacare repeal and Republican members facing protests at home over losing Medicaid expansion.
Senate leaders delayed a vote on their version of a replacement for the Affordable Care Act (ACA) until after the July 4 recess, after multiple senators said they were not ready to vote on the bill as written.
Senate Majority Leader Mitch McConnell (R-Kentucky) had hoped to hold a floor vote before the holiday break, but by Tuesday afternoon, at least 5 Republicans had said they would not support a procedural vote to open debate on the plan. Republican senators publicly opposed are moderates Susan Collins of Maine and Dean Heller of Nevada, and conservatives Rand Paul of Kentucky, Mike Lee of Utah, and Ron Johnson of Wisconsin. No Democrats are supporting the Senate repeal plan.
That was enough to halt the bill, which on Monday received a score from the Congressional Budget Office (CBO), deeming it marginally less likely to cause Americans to become uninsured over the next decade than the House plan, but more likely to cause them to lose coverage in the in next year.
CBO found that 22 million more people would become uninsured by 2026 than under current law, returning uninsured levels to where they were before the ACA took effect. Monday’s analysis found that 15 million would lose coverage in the first year as requirements to stay insured lapsed. Savings would be $321 billion by 2026, or $202 billion higher than a competing replacement plan passed by the House on May 4, 2017.
Healthcare groups and others opposed to ACA repeal have targeted Republican senators in states where support for Medicaid expansion is strong, or where the opioid epidemic would make its elimination deeply felt. Senator Shelley Moore Capito, R-West Virginia, has had picketers camped in her office, and 6 were arrested.
Opposition wasn’t just forming in states like Ohio, where Republican Governor John Kasich has warned against scuttling Medicaid expansion. A spokesman for Senator Thad Cochran of Mississippi, who survived a primary scare in his last election with crossover votes from African Americans, told POLITICO that calls to the office were overwhelmingly against the Senate bill.
McConnell’s dilemma is that he was losing votes from both ends of the spectrum. Conservatives like Paul said the Senate plan did not do enough to repeal Obamacare, while senators like Collins and Lisa Murkowski of Alaska worried about the effects on those who have come to rely on Medicaid or who have preexisting conditions. Senator Lindsey Graham of South Carolina summed it up when he told Vox “you’re either gonna get 50 or probably 35,” and that the CBO estimate had made things more challenging.
HHS Secretary Tom Price, MD, and President Donald J. Trump have both questioned the accuracy of CBO's estimates, citing the fact that the CBO had predicted millions more would sign up for coverage on the ACA's exchanges than actually did.
Conservatives, meanwhile, say the Senate plan doesn’t do enough to lower premiums. Monday’s CBO report found that premiums would go down by 2020, but not without higher out-of-pocket costs. Other analyses have found the savings would be uneven—costs for younger Americans would go down the most, while a small business group said the Senate plan would “devastate” small business owners.