Senate Republicans again failed to approve legislation to repeal major parts of the Affordable Care Act on Wednesday.
This time, it was a bill that would have eliminated funding for the Affordable Care Act’s private health insurance subsidies and Medicaid expansion, its individual mandate that most Americans obtain health coverage or face tax penalties, its mandate that large companies offer health benefits to full-time employees, and its taxes on rich people and health care companies. This legislation didn’t include any means of replacing the Affordable Care Act.
The measure, known as as the Obamacare Repeal Reconciliation Act, failed 45-55, with seven Republican senators voting against it, along with all Democrats and independents in the upper chamber. GOP Sens. Lamar Alexander (Tenn.), Susan Collins (Maine), Dean Heller (Nev.), John McCain (Ariz.), Shelley Moore Capito (W. Va.), Lisa Murkowski (Alaska) and Rob Portman (Ohio) opposed the legislation.
The path forward for Senate Majority Leader Mitch McConnell (R-Ky.) isn’t clear, but the defeat of another bill doesn’t mean the Affordable Care Act is safe.
The Senate will continue debating health care throughout the week, with a slew of additional votes coming, many of which are expected to occur between Thursday evening and into the wee hours of Friday morning. Republican senators at this point appear increasingly content to pass essentially anything, regardless of its policy content and its consequences for the health care system.
The Obamacare Repeal Reconciliation Act would have increased the number of Americans without health coverage by 32 million over the next 10 years, according to the Congressional Budget Office, including 17 million people who would have become uninsured next year alone.
The bill also would’ve upended the health insurance market by eliminating the individual mandate, which encourages healthy people to buy insurance, but would have left in place rules guaranteeing access to coverage for people with pre-existing conditions and promising a rich set of insurance benefits.
As a result, fewer healthy people would have enrolled, and those who remained in the market would have generally been sicker and more expensive to care for, which would have driven up premiums over time. In addition, the absence of financial assistance for private insurance would have kept away low-income customers, both healthy and sick.
On Tuesday, the Senate voted to begin debate on health care legislation by the barest of margins: Vice President Mike Pence had to cast a tie-breaking vote in his constitutional role as president of the Senate after GOP Sens. Susan Collins (Maine) and Lisa Murkowski (Alaska) voted against the motion to proceed to the bills, joining all 46 Democrats and both independents in the Senate.
But too few Republicans backed the first two vehicles for Obamacare repeal for the measures to move forward. The Senate rejected the Better Care Reconciliation Act, previously the leading contender to repeal and “replace” the Affordable Care Act, 43-57 on Tuesday evening, with nine Republicans voting to oppose it alongside all the minority senators.
That bill would have increased the number of uninsured Americans by 22 million over a decade and disrupted the insurance market, especially for older, poorer and sicker people, the Congressional Budget Office concluded.
The bill that failed Wednesday, unlike the Better Care Reconciliation Act, didn’t include any language to actually replace the Affordable Care Act. In addition, it didn’t actually repeal the entire law. Largely because of the restrictions of the budget reconciliation process, which McConnell is employing for the Obamacare repeal effort, the legislation couldn’t undo significant elements of the health care law, such as its regulations on health insurance policies.
The budget reconciliation process enables McConnell to win final passage of legislation with a simple majority because budget reconciliation bills aren’t subject to filibusters. But it also limits legislation to matters directly affecting the federal budget, which doesn’t include things like creating new programs or changing regulations.
Six Republican senators who voted for that measure two years ago opposed it this time: Alexander, Capito, Heller, McCain, Murkowski and Portman. Collins and then-Sen. Mark Kirk (Ill.) were the only Republicans who opposed the 2015 legislation.
After this latest unsuccessful vote, the most likely scenario, for now, is that McConnell presents the Senate with a new, so-called “skinny” bill ― written on the fly ― that would merely repeal the Affordable Care Act’s individual and employer mandates, along with its tax on medical device sales.
The Congressional Budget Office analyzed the effects of repealing only the individual mandate in a 2015 report, and found it would destabilize the health insurance market, leading to 15 million fewer people with coverage and 20 percent health insurance premium increases. The budget agency didn’t project the effects of eliminating the employer mandate and the medical device tax in that report.
If McConnell chooses this option, it would force Republicans in the Senate and the House, which passed its own version of repeal-and-replace legislation in May, to negotiate still another health care bill that leaders would ask their members to support. President Donald Trump has been clear that he will sign whatever health care bill Congress sends him.
CORRECTION: A previous version of this story mistakenly omitted Sen. Lamar Alexander as one of the Republicans who voted no on Wednesday.