Ear to the door: Five things being weighed in secret health bill also weigh it down
Anyone following the debate over the “repeal and replace” of the Affordable Care Act knows that the 13 Republican senators writing the bill are meeting behind closed doors.
While Senate Majority Leader Mitch McConnell (R-Ky.) continues to push for a vote before the July 4 Senate recess, Washington’s favorite parlor game has become guessing what is, or will be, in the Senate bill.
Spoiler: No one knows what the final Senate bill will look like – not even those writing it.
“It’s an iterative process,” Senate Majority Whip John Cornyn (R-Texas) told Politico, adding that senators in the room are sending options to the Congressional Budget Office to try to figure out, in general, how much they would cost. Those conversations between senators and the CBO – common for lawmakers working on major, complex pieces of legislation – sometimes prompt members to press through and other times to change course.
Although specifics, to the extent there are any, have largely stayed secret, some of the policies under consideration have slipped out, and pressure points of the debate are fairly clear. Anything can happen, but here’s what we know so far:
1. Medicaid expansion
The Republicans are determined to roll back the expansion of Medicaid under the Affordable Care Act. The question is, How to do it? The ACA called for an expansion of the Medicaid program for those with low incomes to everyone who earns less than 133% of poverty (around $16,000 a year for an individual), with the federal government footing much of the bill. The Supreme Court ruled in 2012 that the expansion was optional for states, but 31 have done so, providing new coverage to an estimated 14 million people.
The Republican bill passed by the House on May 4 would phase out the federal funding for those made eligible by the ACA over 2 years, beginning in 2020. But, Republican moderates in the Senate want a much slower end to the additional federal aid. Several have suggested that they could accept a 7-year phaseout.
Keeping the federal expansion money flowing that long, however, would cut into the bill’s budget savings. That matters: In order to protect the Senate’s ability to pass the bill under budget rules that require only a simple majority rather than 60 votes, the bill’s savings must at least match those of the House version. Any extra money spent on Medicaid expansion would have to be cut elsewhere.
2. Medicaid caps
A related issue is whether and at what level to cap federal Medicaid spending. Medicaid currently covers more than 70 million low-income people. Medicaid covers half of all births and half of the nation’s bill for long-term care, including nursing home stays. Right now, the federal government matches whatever states spend at least 50-50 and provides more matching funds for less wealthy states.
The House bill would, for the first time, cap the amount the federal government provides to states for their Medicaid programs. The CBO estimated that the caps would put more of the financial burden for the program on states, which would respond by a combination of cutting payments to health care providers like doctors and hospitals, eliminating benefits for patients, and restricting eligibility.
The Medicaid cap may or may not be included in the Senate bill, depending on whom you ask. However, sources with direct knowledge of the negotiations say the real sticking point is not whether or not to impose a cap – they want to do that. The hurdles are how to be fair to states that get less federal money and how fast the caps should rise.
Again, if the Senate proposal is more generous than the House’s version, it will be harder to meet the bill’s required budget targets.
3. Restrictions on abortion coverage
The senators are actively considering two measures that would limit funding for abortions, though it is not clear if either would be allowed to remain in the bill according to the Senate’s rules. The Senate Parliamentarian, who must review the bill after the senators complete it but before it comes to the floor, will decide.
The House-passed bill would ban the use of federal tax credits to purchase private coverage that includes abortion as a benefit. This is a key demand for a large portion of the Republican base. However, the Senate version of the bill must abide by strict rules that limit its content to provisions that directly impact the federal budget. In the past, abortion language in budget bills has been ruled out of order.
