The Senate Health-Care Vote-O-Rama: A Guide for the Perplexed

Are you confused by what’s happening as the Senate debates various
health-care-reform proposals? Join the club. “I read and analyze health
legislation for a living. And I’m having trouble keeping up with the big
and complicated changes in real time,” Larry Levitt, a senior
vice-president at the Kaiser Family Foundation,
tweeted on Tuesday night, as a series of votes began. On Wednesday, there were more votes, and there will be still more on Thursday—many of them as the process climaxes in a so-called Vote-O-Rama.

Many of these votes don’t mean much: they concern Democratic amendments
that have no chance of passing. But some of the votes are highly
consequential, and two of them have already delivered significant
setbacks to the Republican Party leadership. On Tuesday night, an
amended version of the Better Care Reconciliation Act, Senate Majority Leader Mitch McConnell’s
proposal to repeal and replace the Affordable Care Act, was
defeated,
with fifty-seven senators voting against it, including nine Republicans.
And, on Wednesday afternoon, a proposal to repeal Obamacare but put off a
replacement for two years, which was McConnell’s Plan B, was also
defeated,
this time with fifty-five senators against it.

Much of the news coverage and commentary then began to focus on the last
remaining big vote, on a so-called skinny-repeal bill, which could
take place late Thursday. Skinny repeal could be considered McConnell’s
Plan C. But before considering the details of this proposal it is worth
dwelling for a moment on what has already happened. Earlier this week,
McConnell got senators to agree to start a floor debate without knowing
what sort of proposals would be considered. This cynical tactic gave new
life to the Republican effort to repeal Obamacare. The subsequent votes
then represented an important victory for everybody who has opposed the
Republicans’ plans, and especially those who have sought to exert
pressure on elected G.O.P. officials.

In failing to pass either a repeal-and-replace bill or a repeal-only
bill, the G.O.P. has publicly demonstrated that it’s too fractured to turn
history back to before March of 2010, when the A.C.A. became law. The effort to resurrect the Better Care Reconciliation Act ran into opposition from ultra-conservative senators, such as Mike Lee
and Rand Paul, who didn’t think the bill went far enough, as well as
moderate Republicans, such as Susan Collins, Dean Heller, and Lisa
Murkowski, who were concerned about the slashing cuts to Medicaid that
the measure contained. Then, in opposing the repeal-only bill, which
would have created great uncertainty for tens of millions of Americans
and chaos in the health-care industry, four more moderates joined
Collins, Heller, and Murkowski: Lamar Alexander, Shelley Moore Capito,
John McCain, and Rob Portman.

Taken together, these votes suggest that it is now highly likely that a good
deal of Obamacare will remain in place—the unresolved question is just
how much.

If you believe the news reports about what the skinny-repeal bill will
look like when McConnell finally releases it, most of the A.C.A. appears
likely to emerge unscathed, including the Medicaid expansion, which has
enabled about fourteen million Americans to get health care; the
Obamacare exchanges, where more than twelve million people signed up
this year to purchase private insurance; the federal subsidies that
greatly reduce the cost of these policies for low-to-middle-income
households; the regulations that force insurers to offer comprehensive
policies; the prohibition on insurers barring people with preëxisting
conditions; and the taxes on the one per cent that help to finance the
system. A number of reports say that the skinny-repeal bill would
target only the individual and employer mandates, as well as the taxes
on medical devices.

Of course, these reports could be wrong. And, in any case, it is unwise
to take at face value anything that McConnell plans to do. Repealing the
two mandates would have broad and damaging repercussions. According to a
2015 analysis by the
Congressional Budget Office, eliminating the individual mandate would
increase the number of uninsured by about fifteen million over a decade
and raise premiums for everybody else by about twenty per cent. Among
health-care experts, there is debate about whether, as enrollment in
insurance plans fell and prices rose, the Obamacare exchanges could then
eventually enter a death spiral. On Wednesday, Levitt
warned about this as a serious possibility. Loren Adler, an analyst at the
Brookings Institution,
said that
although repealing the mandates would create some serious problems, it
would not be sufficient to destroy the insurance exchanges, because the
continued availability of the federal subsidies would prevent the number
of enrollees from falling too far.

The other, even bigger, problem with the skinny-repeal bill is that it
likely won’t be designed to be the final version of the Republican
legislation. Practically everybody on Capitol Hill believes that
McConnell is putting it forward as a ruse to toss the ball to a
House-Senate conference, which could then come back with a much broader
bill that would torpedo the insurance exchanges, roll back the Medicaid
expansion, and get rid of the taxes on the rich.

“GOP leaders would craft that version behind closed doors during
Congress’ August recess and in early September,” Bob Greenstein, the
president of the Center on Budget and Policy Priorities, warned in a
blog
post
on Wednesday. “They would then present it to the House and Senate for
final votes later in September, with limited debate and no amendments
allowed—and with GOP leaders applying maximum pressure on Republican
senators and House members to fall in line. In short, the ‘skinny
repeal’ bill is a Trojan horse designed to resuscitate the effort to
repeal large parts of the ACA and impose big Medicaid cuts that would
jeopardize coverage for millions of the nation’s neediest people.”

Based on McConnell’s record, there is every reason to suppose that he
would very much like this scenario to play out as Greenstein described
it. After the votes on Tuesday and Wednesday, however, many people on
Capitol Hill are doubtful that even the Senate Majority Leader, with all
his Machiavellian ways, will be able to pull it off. “Almost every GOP
aide I’ve talked to—both House and Senate—are skeptical that a
conference committee will come up with something that can pass the
Senate,” Axios’s Caitlin Owens reported on Wednesday evening. “If the Senate couldn’t accomplish this feat
itself, the reasoning goes, why would a conference committee that must
bridge the gap between Senate moderates and the House Freedom Caucus?”

If the skinny-repeal bill got through the Senate, but the effort to
put together a more comprehensive piece of legislation then failed, the
Republican leaders from both houses could conceivably settle for making
the Senate bill law—and Donald Trump could conceivably declare victory
on health care and move on. But I am getting ahead of the story. Right
now, it isn’t entirely clear if McConnell will get anything passed at
all, and the most effective way to insure that the G.O.P.’s effort to
wreck Obamacare is permanently frustrated would be to prevent the
skinny-repeal bill from getting fifty-one votes. If that is what you
would like to see happen, and especially if you live in a red state,
this is a good day to call your senator.

*This post has been updated to clarify when the Vote-O-Rama begins.

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