By Sean Sullivan, Juliet Eilperin and Kelsey Snell | Washington Post
WASHINGTON — Senate Republican leaders secured the votes they needed on Tuesday to begin debating health-care legislation, in a dramatic reversal of fortune for their beleaguered health-care effort.
While the move put them one step closer to actually repealing-and-replacing the Affordable Care Act, it remained unclear how much they could modify the law, given the deep policy schism that still separates conservatives from centrists in the GOP.
The 51 to 50 vote, in which Vice President Mike Pence broke the tie, now puts Republicans in the position of taking up legislation that would affect one-sixth of the nation’s economy and how tens of millions Americans receive medical treatment.
All 48 Democrats voted against the procedural motion, along with two GOP centrists, Susan Collins, Maine, and Lisa Murkowski, Alaska, voted against the motion to proceed.
But the GOP has struggled mightily to get to this point, and there is no guarantee they will win final passage of a bill changing Obamacare. In a sign of how muddled the situation remains, Sen. John McCain, R-Ariz. took to the floor after voting to move ahead and declared, “I will not vote for the bill as it is today. It’s a shell of a bill right now.”
Sen. Jerry Moran, R-Kan., echoed these sentiments, tweeting, “I support a full repeal of Obamacare & will continue to oppose the BCRA.”
President Donald Trump has been pushing aggressively for Republicans to pass a repeal-and-replace plan, and jabbed lawmakers this week by saying anyone who votes against kicking off debate is saying they are “fine with the Obamacare nightmare.” Speaking during a joint news conference in the Rose Garden Tuesday, Trump said he was “very very sad” for the Republicans who opposed the motion but “very happy with the result” of the vote.
“Now we’re all going to sit together and try to come up with something really spectacular,” the president said, though he acknowledged Republicans face “a narrow path” on health care. “It’s a very, very complex and difficult task, something I know quite a bit about.”
Republican leaders now see a scaled-down version of the bill as perhaps their best chance of winning final passage on some kind of measure to overhaul Obamacare. If senators passed this stripped-down version – which some Republicans refer to as “skinny repeal” – they would set up a House-Senate conference to resolve the differences between the two proposals, buying Republicans more time.
The new strategy will allow Republicans to sustain their years-long effort to unwind the 2010 health-care law, though they have yet settle on a replacement for it. But it is also is a tacit acknowledgment that more sweeping efforts to revise or even simply repeal the law cannot succeed, even as Republicans control both Congress and the White House.
Under pressure from President Trump and determined to deliver on a promise that helped fuel their political rise, Senate Republicans have coalesced around the idea that it is worth embarking on an unpredictable series of votes rather than abandon the effort altogether.
“They expect us to tackle the big problems,” McConnell said on the Senate floor, referring to American voters. “All we have to do today is have the courage to begin the debate. . . and let the voting take us where it will.”
The vote was marked by high drama, with Democrats waiting for Republicans to show where they stood before casting their votes.
A group of protesters cried out “Kill the bill!” as voting began, prompting Capitol police officers to escort them out of the chamber, with their hand tied behind their backs in plastic handcuffs.
The Senate GOP’s top vote counter, John Cornyn, R-Texas, spoke for several minutes with fellow Republican Ron Johnson, Wis., before he cast his yes vote. Health and Human Services Secretary Tom Price, whom Trump teasingly threatened to fire if the motion did not pass, huddled on the floor during the roll call with Rep. Roy Blunt, R-Mo. And when the ailing McCain walked on the floor, the assembled senators burst out in applause.
Senate Minority Leader Charles Schumer, D-N.Y., made one final plea to Republicans before the vote started. “Turn back. We can go through regular order. We want to work with you,” he said. “Turn back, before it’s too late.”
Republicans are expected to vote on several different versions of health-care legislation before getting toa final outcome – including a straight repeal of the ACA and the bill produced by McConnell that has so far failed to gain traction among Senate Republicans.
The “skinny bill” leaders are now considering would repeal the ACA’s mandates that both individuals buy plans and that employer with 50 or more employees provide coverage, according to lobbyists and Senate aides, as well as eliminate the law’s tax on medical device manufacturers. But individuals briefed on this plan, who asked for anonymity because it had not been formally announced, said they could not predict whether it would ultimately pass.
McCain, who was recently diagnosed with an aggressive form of brain cancer, arrived at the Capitol after the vote was underway. His decision to return to Washington a week and-half after undergoing surgery helped turn the tide for GOP leaders, though the precise outcome of the vote remained in doubt until early Tuesday afternoon, several senators who were previously opposed to moving ahead with the health-care debate announced they had changed their minds.
They included GOP Sens. Shelley Moore Capito, W.Va., Dean Heller, Nev., Rob Portman, Ohio, Mike Lee, Utah, and Jerry Moran, Kan., all of whom have raised serious concerns about McConnell’s plan to rewrite the ACA.
“Obamacare isn’t the answer, but doing nothing to try to solve the problems it has created isn’t the answer either. That is why I will vote to move forward and give us a chance to address the unworkable aspects of the law,” Heller said.
Capito vowed in a statement that as the process advanced in the Senate “will continue to push for policies that will result in affordable health care coverage for West Virginians, including those who are in the Medicaid population and those struggling with opioid addiction.”
On the Senate floor, McConnell called the procedural vote “a critical first step” in unwinding the landmark 2010 health care law.
As the scheduled vote neared, McConnell said Republican senators had a chance to follow through on a seven-year promise to repeal the Affordable Care Act. He also repeated the thinly-veiled threat Trump leveled in a speech a day earlier: a vote to block debate on repeal is a vote to save Obamacare.
“Any senator who votes against starting debate is telling America that you’re just fine with the Obamacare nightmare,” McConnell said. “I would urge them to remember the families who are hurting under this collapsing law.”
McConnell is currently planning to file motions to bring up the House-passed health bill and modify it in several ways, according to several individuals briefed on the plan who asked for anonymity to discuss private conversations, with several types of amendments. These amendments are expected to include some version of a more recent Senate health care bill with modifications by both Sen. Ted Cruz, R-Texas, and Portman. A separate vote would be held on version of a 2015 bill repealing the law outright after a two-year transition.
The Cruz proposal would allow insurers to offer coverage on the ACA market that does not include all the benefits currently required under the law, as long as they provided one fully-compliant plan. The Portman amendment would add an additional $100 billion in flexible spending under Medicaid, according to these individuals.
To win over a handful of centrist senators, who have expressed concern about the bill’s deep cuts to Medicaid and its phaseout of the program’s expansion under the ACA, top administration officials have promised lawmakers more flexibility and extra funding to help transition millions of low-income Americans onto private insurance.
Seema Verma, director of the Health and Human Services Department’s Centers for Medicare and Medicaid Services, has provided some Republicans an analysis of how the bill would affect people covered by the expansion in their states, according to individuals briefed on the matter. They said Verma has suggested that money in the bill could help state residents pay premiums to obtain the lowest-level plans on the ACA-market, known as “bronze” plans and has promised up to $100 billion in flexible Medicaid funding.
Vice President Pence and White House legislative affairs director Marc Short attended Tuesday’s lunch, Short said Tuesday. He said the president has been placing calls “to a couple of members” in hopes of rounding up the votes to proceed to the bill. He said the administration has also serves as a resource to provide “technical assistance” to senators looking to get policy questions answered as they make up their minds.
On Tuesday a coalition of medical and consumer groups reiterated their intense opposition to all the health-care plans Senate Republicans have been considering, calling on them to drop those bills and begin anew with a bipartisan process that includes standard committee hearings.
In a conference call, David Barbe, the president of the American Medical Association and part of the coalition, challenged the claims Senate GOP leaders have made about their main legislation to dismantle large parts of the Affordable Care Act.
“It does not make care more affordable to low-income Americans,” Barbe said. “It does not reduce out-of-pocket costs. It could trigger substantial increases for patients with preexisting conditions.”
Democrats are eyeing the developing GOP tactics nervously. A bill repealing only the ACA’s most unpopular parts could prove more attractive to Republican moderates. But once the Senate and House go to conference on health-care legislation, more conservative House members will likely try to expand its provisions repealing key elements of the existing law.