WASHINGTON ― Senate Republicans are still moving ahead with a vote on their health care bill next week, but barring some sudden changes of hearts, it looks like they will fall short of the votes ― and no one seems to have a real idea of what to do then.
Majority Leader Mitch McConnell (R-Ky.) is expected to release the text of a revised bill Thursday, along with an amendment drafted by Sen. Ted Cruz (R-Texas) that would dramatically undermine protections for people with pre-existing conditions in the name of lowering costs for healthy people. On Wednesday afternoon, Cruz suggested, but did not directly state, that he would vote against the motion to proceed on the bill if his amendment was not attached.
“If there are not meaningful protections for consumer freedom that will lower premiums, then the bill will not go forward,” Cruz said.
Pressed on whether that meant he would vote against a motion to proceed, Cruz said the bill would not “have the votes” to go forward. The Cruz amendment would allow insurers who offer at least one health plan that complies with Obamacare regulations to offer other, cheaper plans that don’t.
Regardless of whether Cruz’s amendment is included, a vote on the motion to proceed may be going down anyway. Sen. Susan Collins (R-Maine) told Politico on Tuesday she was “not optimistic” that this would be a bill she could support, and Sen. Dean Heller (R-Nev.) famously expressed a number of issues with the bill in a high-profile news conference in June ― issues that would largely be exacerbated or unaddressed with the addition of Cruz’s amendment.
Sen. Rand Paul (R-Ky.) has also strongly suggested he would vote against a motion to proceed on the revised bill no matter the status of Cruz’s amendment. He called it “the same as the old bill, except worse,” and, should a motion to proceed fail, he would push Senate GOP leaders to hold a vote on a straight repeal.
“I ran on repealing Obamacare,” Paul told reporters Wednesday. “It doesn’t repeal Obamacare. It creates a giant Obamacare superfund. I can’t be for that.”
“If they lose on this vote, I’m giving them an alternative,” Paul said. “The alternative is two bills: clean repeal, and a big government spending bill that they can work with Democrats on for big government-spending Republicans.”
Republicans seem to acknowledge that they will, at some point, need to stabilize Obamacare markets. Even in their bill replacing the Affordable Care Act, there are funds that would reimburse insurers for the cost of their most expensive patients, allowing them to hold down premium increases.
But without their bill, many Republicans concede they should do something to bring more certainty to insurers offering plans in 2018.
I ran on repealing Obamacare. It doesn’t repeal Obamacare. It creates a giant Obamacare superfund. I can’t be for that. Sen. Rand Paul (R-Ky.)
At a minimum, Sen. Ron Johnson (R-Wis.) has suggested Republicans could fund the so-called cost-sharing reductions (CSRs), which subsidize the cost of Obamacare plans for people with incomes up to 250 percent of the poverty level. President Donald Trump has threatened to end those payments, and, in response to that uncertainty, insurers have offered more expensive plans or simply not offered plans at all.
Funding those CSR payments would be a small step that Republicans could take ― with Democrats ― to reinforce the Obamacare insurance markets. But that move would almost certainly draw the ire of conservatives, and it’s unclear what legislative vehicle Congress could use for CSRs.
A budget deal or debt ceiling increase with Democrats would be an obvious choice, but there’s little impetus to pass one of those bills at this point, and Republicans would functionally be giving up on their repeal efforts and removing the one negotiating chip they may have to force Democrats to the table on a bipartisan health care bill.
A more likely scenario ― the actual bare minimum ― is that Republicans do nothing. The Trump administration could continue to make the CSR payments or could end them and truly throw the Obamacare exchanges into chaos. Trump has the CSR payments as leverage to extract concessions on other priorities, like his wall along the Mexican border in an omnibus spending deal, and he could make the subsidies contingent upon an item like that funding.
It would then be up to Democrats whether they would give in to Trump’s demands or gamble that voters will just blame Republicans for the collapse of the insurance market and, perhaps, a government shutdown.
That potential showdown is all the more reason some Republicans are floating the idea of working with Democrats on new legislation.
Sen. Lindsey Graham (R-S.C.) claims to already be working on a bipartisan health care bill ― a strategy endorsed by more moderate Republicans, such as Collins and Lisa Murkowski (R-Alaska) ― but his idea of a bipartisan measure at this point sounds less than half-baked and far short of bipartisan.
“We’re trying to find consensus among ourselves and at the same time reach out to some Democrats who would be open-minded to the solutions being at the state level, not necessarily in Washington,” Graham said Wednesday.
If that sounds like like something Democrats might resist, it probably should. Graham’s idea of Democrats jumping aboard seems more aspirational than real.
“It is a concept,” he said. “I hope it can get bipartisanship.”
Asked about the basic tenets of his health care bill, Graham declined to provide any real details until Republicans had either passed or dispensed with their current legislation. (Graham said he thought the bill coming to the floor next week would fail.)
But the GOP’s best hope of getting a bill through still seems to be this week’s revised legislation. While the health care plan continued to appear short on support Wednesday, McConnell still has more than $400 billion in savings he can dole out to win over reluctant Republicans. Many of Murkowski’s concerns for Alaska could be addressed with that money, as could some concerns of other Republicans over the phaseout of the Medicaid expansion and high premiums for low-income seniors, though aides and senators have indicated that the new bill will mostly preserve the current provisions on ending the Medicaid expansion.
McConnell could also get a helping hand from the Senate parliamentarian, as she’ll have to rule on whether Cruz’s open-ended language on coverage options is actually allowable in a reconciliation bill, which requires only 50 votes to pass but limits what senators can do in order to reconcile spending with their budget. While striking down the Cruz language could be the death blow for the health care bill, it could also convince Cruz and other conservatives ― like Mike Lee (R-Utah) ― to accept a more incremental approach.
At this point, McConnell seems to need a shakeup, and a parliamentary ruling could be what shifts the current dynamics.
The idea, however, of Republicans going back to the drawing board, perhaps seeking out some Democrats to support their measure, doesn’t look like a winning strategy. Republicans are already split over a health care bill for both repealing too much of Obamacare and not enough, and Democrats appear completely united in their opposition to anything resembling the Republican plan.
If the revised bill fails, GOP senators have little idea what Plan B is. “I’ll leave that up to the leadership to decide what to do,” Sen. Richard Burr (R-N.C.) said Wednesday. “You’re going to have a health care system that implodes.”
As it happens, that part isn’t entirely true. The markets appear to be in better shape than Burr and his allies concede ― or perhaps even realize. Just this week, the Henry J. Kaiser Family Foundation released a study of insurer financial performance that concluded “the individual market has been stabilizing and insurers are regaining profitability.”
Premiums or out-of-pocket costs remain a lot higher than many people feel they can afford, and insurer pullouts have left some areas, particularly rural ones, with few or even no choice of insurers. But some carriers are expanding their options, filling in gaps others are leaving, and many industry officials say the biggest source of uncertainty isn’t the underlying market weakness that plagued the program in its first few years; it’s the neglect and sabotage from hostile officials, including the ones working out of the White House.
With a little more money, or at least some assurances that the existing money will continue, the worst outcomes of an Obamacare market collapse could be avoided.
But Republicans don’t look all that interested in that white flag approach ― at least not until they’ve demonstrated they can’t pass a bill of their own. And even then, Republican leaders see big problems if they can’t muscle through this health care legislation.
Asked on Wednesday what Republicans would do if they couldn’t pass their bill, GOP Conference Chairman John Thune (R-S.D.) suggested Republicans didn’t have a backup plan.
“That would be highly problematic,” Thune said.
Jonathan Cohn contributed to this report.
CORRECTION: This article previously misstated the upper threshold for CSRs as 400 percent of the poverty level; the correct figure is 250 percent of the poverty level.