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    Republican effort to repeal the Affordable Care Act (also known as Obamacare) again hits a snag

    Americas: United States


    Republican effort to repeal the Affordable Care Act (also known as Obamacare) again hits a snag




    In May 2017, the Republican-controlled United States House of Representatives narrowly approved a bill to repeal the Affordable Care Act, the signature Democratic health care bill known colloquially as Obamacare that went into effect during the first term of Obama’s presidency.  In June 2017, the Republican-led Senate of the United States put forth its version of the Obamacare repeal and replacement plan.  However, criticism of the plan was impeding the necessary unified Republican support in the Senate and ultimately forced the Republican leadership in the upper chamber to delay a vote on its passage.  It was to be seen if deal-making, persuasion and pressure could end these objections, and ultimately facilitate the bill's passage. In July 2017, passage of the bill was ultimately defeated by a handful yet sufficient number of Republican Senators objecting to the bill on different ideological grounds. This prompted Senator McConnell to immediately revive a 2015 reconciliation bill that provided for the repeal of Obamacare’s taxes and spending, but this was swiftly undone when another handful yet sufficient number of Republican Senators stated they would vote against repeal so long as a satisfactory replacement was not on the table.  The climate shifted at the close of July 2017, thanks to pressure from President Trump, as Republican Senators unified behind voting for motion to proceed on Obamacare’s repeal. However, the Senate GOP’s efforts to repeal the Affordable Care Act ultimately suffered defeat, as the Better Care Reconciliation Act (BCRA), the 2015 ACA repeal bill, and the “skinny repeal” bill —- a last ditch effort by the Senate GOP to make incremental progress on ACA’s repeal —- all were voted down by Democrats in the Senate joined by a sufficient number of Republican defectors. President Trump reacted by threatening to financially sabotage Obamacare by withholding payments.   In September 2017, Republicans were ramping up a new effort to try to repeal Obamacare; however, that endeavor was expected to end in failure as before..


    In Detail


    On May 4, 2017, the Republican-controlled United States House of Representatives narrowly approved a bill to repeal the Affordable Care Act, the signature Democratic health care bill known colloquially as Obamacare that went into effect during the Obama presidency.  


    Obamacare, which allowed more than 20 million Americans access to health insurance, has long been at the top of Republicans' target list to excise.  That goal was partially achieved in the lower house, and gave President Donald Trump a political victory in making significant progress on fulfilling a campaign promise.  


    Central to the Republicans' plan, called the American Health Care Act, were provisions to:


    - repeal most Obamacare taxes, which funded the program

    - roll back the Medicaid expansion, which provided affordable care to the indigent

    - remove most of the program’s funding

    - repeal the penalty for not purchasing insurance 

    - replace tax credits with flat age-based credits


    The bill passed 217-213, with not one Democratic vote in its favor and twenty Republicans joining them in objection.


    The legislation would thus be sent to the Senate where it would have to either considered and/or reconciled with that chamber's version.  Objections to the health care repeal were expected to be strong, even from among Republicans, due to aspects of the bill that would allow states to discontinue coverage for individuals with pre-existing conditions, as well as other strictures that would result in onerous costs for people, or lost health care altogether. 


    Nevertheless, Republicans in the House celebrated their success in killing Obamacare, with trucks carrying beer arriving at the Capitol for a party of sorts.  On the same day, President Tump, in the Rose Garden of the White House, declared: "I went through two years of campaigning and I'm telling you, no matter where I went, people were suffering so badly with the ravages of Obamacare." He added, "We are going to get this passed through the Senate. I am so confident."


    It should be noted that this legislation was voted on in the House of Representatives before it could be assessed by the non-partisan Congressional Budget Office, which estimates costs and effects on insurance rolls.


    In June 2017, the Republican-led Senate of the United States put forth its version of the Obamacare repeal and replacement plan.  This reconciliation bill was titled "Better Care Reconciliation Act of 2017" or BCRA. 


    There was significant criticism for the Republican health bill because of its cuts to Medicaid -- a program that helps the most impoverished Americans receive health care coverage.  That criticism was particularly amplified given the fact that the health plan also provided impressive tax cuts for the richest echelon of society. As such, there was an unflattering characterization of the Republican health plan as "reverse Robin Hood-ism," with tax breaks for the ultra-wealthy being paid for via increased pain and suffering for the lowest income brackets.  


    When asked about this particular angle in an interview with an ABC news reporter, President Trump brushed aside this suggestion, saying instead: "This will be great for everyone."  It was unclear how less Medicaid benefits would actually benefit the poorest Americans dependent on the aide program. 


    Democrats were voicing their objections to the Republican health plan with senators taking to the floor to excoriate the proposed bill as heartless, and making note that it was actually a tax break for the rich masquerading as a health plan.  Some Democratic senators even took part in a "sit in" at the Capitol to protest the bill. 


    On June 26, 2017, the Congressional Budget Office (CBO) issued its score for the Republican Senate health bill, BCRA,  and it was highly unfavorable.  Of note was the fact that the Republican plan would significantly increase -- rather than decrease -- the number of already uninsured Americans.  In fact, the CBO score made the following conclusion:


    "The Senate bill would increase the number of people who are uninsured by 22 million in 2026 relative to the number under current law, slightly fewer than the increase in the number of uninsured estimated for the House-passed legislation. By 2026, an estimated 49 million people would be uninsured, compared with 28 million who would lack insurance that year under current law."


    Stated in plain terms, whereas 28 million people lack health insurance under existing conditions, in less than 10 years, that number would skyrocket to just under 50 million, should the Republican health plan take shape.  


    The CBO also concluded that out-of-pocket medical expenses for the working poor would exponentially increase under the Republican health plan.  To that end, the CBO score made the following conclusion:


    "Under this legislation, starting in 2020, the premium for a silver plan would typically be a relatively high percentage of income for low-income people. The deductible for a plan with an actuarial value of 58 percent would be a significantly higher percentage of income—also making such a plan unattractive, but for a different reason. As a result, despite being eligible for premium tax credits, few low-income people would purchase any plan."


    Along a similar vein, the CBO a concluded that out-of-pocket medical expenses for individuals close to retirement would dramatically increase under the Republican health plan. 


    The CBO findings provided cold comfort to conservative market fundamentalists, noting that state waivers advocated by far-right Republicans would actually "cause market instability in some areas” and “would have little effect on the number of people insured."  In fact, many seriously ill people would likely be priced out of the health insurance marketplace entirely and be completely deprived of health care.


    Note:  The complete CBO report can be found via this URL: 


    As June 2017 was coming to a close, Senate Majority Leader Mitch McConnell signaled that the vote on the Republican health care bill would be delayed until after the July 4 (Independence holiday) recess.  In making the announcement, McConnell said, “We will not be on the bill this week, but we will still be working to get at least 50 people in a comfortable place."


    Accordingly, it should be emphasized that the delay on the vote was not a sign that the Republican plan was dead. Instead, it was simply an opportunity for the Republican leadership in the Senate to breathe new life into the proposal, and to dispel doubts of the few Republican holdouts.  Those doubts, though, were emanating from two different factions.  


    For the likes of some deeply conservative Republicans, such as Senator Mike Lee of Utah and Senator Ron Johnson of Wisconsin, the bill was not draconian enough. Overall, far-right conservatives wanted to dispense with Obamacare's regulations that prohibit insurance companies from charging people with more serious illnesses more for health coverage.  They were also demanding that there be more leeway for states to sidestep regulations aimed at protecting consumers (patients).  Also on their list of demands was the call for more funding for tax-free health savings accounts, aimed at incentivizing people to pay for private insurance.


    For the likes of others representing states that went for Obama and Clinton at the presidential level,  such as Senator Dean Heller of Nevada and Senator Susan Collins of Maine, the bill contained harsh measures that they were unwilling to back for political reason.  For senators from states with expanded Medicaid programs, the notion of curtailing this provision was tantamount to snatching benefits away from people.  Also in that category of scaling back (rather than expanding) benefits was the Republican plan to weaken protections for people with pre-existing medical conditions. 


    As such, McConnell's task would be to either balance the polarized interests of these intra-party divisions, or to appease one side sufficiently so that there were enough Republican votes to narrowly pass the bill.  That latter tactic had worked in the House of Representatives when the House leadership in the lower chamber appeased the most conservative representatives, while compelling moderates to fall into line with a narrow offering of incentives. 


    To this end, McConnell said that the postponement was due to a desire to make adjustments in the bill.  As intimated here, it was clear that those changes were aimed at persuading the handful of reluctant Republicans to cease their objections and support the plan.  Moreover, McConnell wanted time to get a new CBO score -- one with more favorable results that might help bring "on the fence" Republican on board, while tamping down public criticism.


    In the lower chamber, House Speaker Paul Ryan was urging House Republicans to allow the process to unfold in the Senate without interference.  By interference, what he meant was that criticism from the House about the provisions of the Senate bill -- including proposed amendments -- were not likely to be helpful in getting it passed.  The goal at hand was to get the legislation passed in the Senate so that the House could come back with its own input after the fact. 


    For his part, President Donald Trump said work was continuing on the Obamacare repeal and replacement plan, and that Republicans were "getting very close" to forging a deal that would pass.  Trump also declared that  Obamacare was "melting down as we speak."  The imperative for the Republican president was as follows: "For the country, we have to have health care and it can't be Obamacare."


    On the other side of the aisle, Senate Minority Leader Chuck Schumer warned Democrats that "the fight was not over."  


    Meanwhile, opposition camps -- political, health policy oriented, socio-economic and otherwise  -- were expected to mount aggressive pressure campaigns to kill the Republican health bill.  Of significance was mounting criticism from doctors, nurses, hospitals, and health care provider groups, along with patient advocacy entities, such as the American Heart Association.


    But the business community had a far different view, with the United States Chamber of Commerce encouraging Senators to support the bill. 


    It was to be seen if deal-making, persuasion, and pressure could end the prevailing objections to the Republican plan in the Senate, and ultimately facilitate the bill's passage.


    Leading up to a vote on the BCRA, three factors contributed to McConnell announcing his intent to delay the vote. First, Senator Rand Paul of Kentucky stated he would vote against the Senate bill on the grounds that it was not a true repeal of the regulatory underpinnings of Obamacare; federal taxes would still be used to pay for subsidies so that people in certain income brackets could purchase private insurance. Second, Senator Collins took to Twitter to declare her intent to vote ‘no’ on motion to proceed citing the fact that the Senate bill still contained severe cuts to Medicaid. Two Senators with disparate lines of objection to the Senate bill combined with a third adventitious factor to lead to McConnell delaying the vote, which was Senator John McCain of Arizona being forced to spend time away from the Senate (reportedly a week or two) to recover from a surgical procedure to remove a blood clot from above his left eye on July 14, 2017. Given that McConnell no longer had a sufficient number of Republican Senators to pass the bill, he announced a delay in voting on the BCRA until Senator McCain had recovered and returned to the Senate. 


    On July 17, 2017, both Senator Mike Lee of Utah and Senator Jerry Moran of Kansas simultaneously announced their intent to vote against motion to proceed on the BCRA with both Senators stating it did not go far enough in repealing Obamacare. Even if Senator McCain was able to return to vote for the BCRA, this announcement effectively killed all chances of the Senate passing the bill.


    Shortly after this was announced, President Trump took to Twitter to encourage Republican Senators to vote on repealing Obamacare now; a replacement would be discussed later, and President Trump anticipated Democrats would join in the process of forging that replacement. Following this announcement, a statement from Senator McConnell’s office announced that the Senate will revive a reconciliation bill from 2015 that repealed Obamacare’s taxes and spending but kept the law’s regulatory framework intact. In 2015, this bill passed in the Senate with 52 Republican votes. At the time, Senator Collins and then-Senator Mark Kirk of Illinois were the only Republicans to vote against this bill.


    On July 18, 2017, Senator Collins announced her intent to vote against the same legislation she voted against in 2015 citing the need for a satisfactory replacement before repeal could be considered. Interestingly, Senator Capito of West Virginia joined Senator Collins in opposition to the revived 2015 bill despite having voted for it in 2015. She specifically cited the growing opioid crisis in her current objection. Senator Lisa Murkowski of Alaska completed the trifecta requisite to stop this bill in its tracks and stated her intent to vote against motion to proceed on the revived 2015 bill. Before Murkowski’s announcement, Senator Rob Portman of Ohio stated that simply repealing without replacing would “add to more uncertainty.” After Murkowski’s announcement, Portman then announced he does not support repeal without replace, citing both the opioid epidemic and the expansion of Medicaid in Ohio. Much like Senator Capito, both Senator Murkowski and Senator Portman voted for this bill back in 2015 when it was President Obama who wielded veto power.


    Senator McConnell announced that the Senate would take up a "motion to proceed" vote early the following week despite it being evident he did not have the votes to even begin debate on the bill. 


    On July 19, 2017, President Trump hosted a lunch at the White House where he pressed 49 of the 52 GOP Senators who attended to agree to a plan to repeal Obamacare before going on August recess. President Trump made clear that any Republican Senator who did not vote for a motion to proceed was essentially affirming that they were “fine with Obamacare.” He took to Twitter  to reiterate the importance of repealing Obamacare by ominously alluding to the repercussions of failing to follow through: “If Republicans don't Repeal and Replace the disastrous ObamaCare, the repercussions will be far greater than any of them understand!”


    On  July 24, 2017, President Trump tweeted about how Republicans had “a last chance to do the right thing on Repeal & Replace” and continued to pressure Republican Senators to unify behind voting for motion to proceed on Obamacare’s repeal. In an afternoon address from the Blue Room at the White House, President Trump delivered an appeal to GOP Senators to keep their promise on repeal and replace of Obamacare in which he derided the Democrats as “obstructionists,” warned Republicans that they need “every single vote” from the GOP caucus, and polemically declared that “Obamacare is death.” Leading up to a motion to proceed vote that was scheduled to occur the following day, reports that John McCain would be well enough to vote were confirmed by his office in a statement that expressed his desire to be present in the legislative chamber for the Senate’s work on health care, defense, and sanctions on Russia.


    The Senate ended up barely passing the motion to proceed vote on July 25, 2017, in a 51-50 vote where Senator  McCain voted for motion to proceed and Vice President Mike Pence was available to break a tie in the Senate. Senators Collins and Murkowski were the only Republican Senators to join all Democratic & independent Senators in opposition to motion to proceed. Following that vote for motion to proceed, Senator McCain took to the Senate floor with a speech imploring the Senate body to forgo partisan rhetoric and parliamentary maneuvers, and generally calling for a return to normalcy. He also stated that he would not vote for the current Senate bill—the BCRA—as it stood that day.


    According to Senate procedure, following the motion to proceed being adopted, debate immediately ensued on the passed House legislation, the AHCA, but Senate rules allow a substitute bill to be offered up for a final vote, which in this case was the BCRA. Senator McConnell offered up the BCRA for a final vote on the same day motion to proceed was agreed to by the Senate body, but this bill required 60 votes to pass due to the inclusion of two amendments that did not conform to the rules for budget reconciliation (where conforming allows for a simple majority to pass) due to the absence of CBO scores. The bill included an amendment from Senator Ted Cruz of Texas for insurers to allow plans that do not adhere to ACA regulations as well as an amendment from Senator Portman of Ohio that would provide some assistance for people on Medicaid. Without any Democratic Senators voting for this bill, it was destined to fail, and fail it did with nine Republicans also voting against it. Of note, Senator McCain voted for this measure after having decried both the bill and the secretive process by which it was created only hours earlier. This vote was a source of confusion due to the fact that, in actuality, it was a procedural vote to determine if the amendment conforms to budget rules, which would mean it could be passed by a simple majority in the future. According to a tweet from Matt Fuller, a former employee of CQ Roll Call, this vote was tantamount to a proxy vote for the BCRA.


    On July 26, 2017, the Senate brought forward the ACA repeal legislation that passed the Senate in 2015 via reconciliation, which meant a simple majority was required to pass. All Democratic Senators and seven Republican Senators voted against this legislation leading to its defeat. Interestingly, of the seven Republican Senators who voted against this legislation, six of them voted for it in 2015. Senator Collins was the only consistent Republican opponent as she voted against it then and again in 2017.


    In tandem with these votes, Republicans were attempting a last ditch effort to address the ACA repeal, which was popularly dubbed the “skinny repeal” bill. Since it was difficult for Senator McConnell to appease both moderate and conservative members of the Senate simultaneously on the issue of ACA’s repeal, this bill was basically a means to accomplish incremental repeal with the hopes of a more comprehensive repeal being plotted out following a conference with the House. The text of the bill was revealed late in the night on July 27 and detailed the following provisions: repeal of the individual mandate, repeal of the employer mandate, a delayed tax on medical devices, cuts to federal funding for Planned Parenthood, increased funding for community health centers, and raising the contribution limits for health savings accounts. The most significant provision, however, would have allowed states to waive federal requirements on plans being required to have a basic set of benefits. Stated differently, it would have reversed key patient-centered regulatory reforms.  


    A strange dynamic played out in the hours leading up to a vote with Republican Senators, such as Senator Lindsey Graham of South Carolina, hoping that voting for the bill would not be followed by the House enacting the same legislation,  This concern that the legislation actually not be activated led Speaker Ryan to release a statement providing assurances that the House and the Senate would negotiate their differences in a conference committee.


    Despite the bill’s popular sobriquet, the CBO’s analysis of the bill concluded the consequences would have been anything but “skinny”; the CBO estimated 15 million more people would be uninsured by next year vs. the current law and premiums would have increased by approximately 20 percent.


    In the early hours of July 28, 2017, the Senate finally brought the “skinny repeal” bill to a suspenseful vote where Senator McCain joined Senators Collins and Murkowski in voting against the legislation; with all Democratic Senators opposed, this constituted a critical blow to Senator McConnell’s efforts to bring ACA repeal to fruition. Senator McConnell’s comments following the failed vote conveyed a sense of finality about the repeal efforts, as he expressed disappointment that they could not achieve repeal of the ACA and suggested that it was time to move from the issue.


    As July 2017 came to a close, President Trump reacted to the failure of his Republican Party to repeal Obamacare by threatening to end cost-sharing subsidies to health insurers. Via Twitter, Trump said, "if a new HealthCare Bill is not approved quickly, BAILOUTS for Insurance Companies and BAILOUTS for Members of Congress will end very soon!"  The president's message on "BAILOUTS for Insurance Companies" appeared to refer to  approximately $8 billion in cost-sharing subsidies paid by the federal government to insurers to lower the price of health coverage for lower-income people. The president's reference to "BAILOUTS for Members of Congress" was a warning that employer contributions for members of Congress and their staff members enjoying healthcare benefits via the insurance exchanges initiated by Obamacare would be halted. Both threats constituted sabotage of the prevailing healthcare policy. Health insurers have indicated that should such measures be undertaken, they would raise premiums by an additional 20 percent by Aug. 16, 2017 (according to the Conference of the National State Legislators), the deadline for premium prices. The president was fully transparent about his intent as he asserted that he would allow Obamacare to “implode.” 


    Note that in September 2017, the Republican effort to repeal the ACA resurfaced in the form of legislation brought forward by Senators Lindsey Graham and Bill Cassidy.   The bill would convert Obamacare’s funding to a block grant, for states to use to enact their own health care solutions although it would also redistribute funding from many Democratic states to Republican ones, according to analysis from the Center on Budget Policy and Priorities.   But even some Republican states, such as Ohio and West Virginia  would lose hundreds of millions of dollars under the block grant.  It was to be seen if senators from those states would sign onto the bill as a result. 


    It should be noted that the proposal would also remove the consumer protections and regulatory reforms that characterized Obamacare, such as protections for people with preexisting conditions.  Moreover, it would overhaul and strip Medicaid.   


    The bill had considerable Republican support but would have to be passed by Sept. 30, 2017 in order to use “budget reconciliation,” which would allow the bill to advance without any Democratic votes.  


    For the bill to be passed, it would have to clear the procedural hurdles to get to the Senate floor.  To get there,  the Senate parliamentarian would have to assess whether or not the plan complies with the chamber’s “budget reconciliation” rules.  As well, the Congressional Budget Office (CBO)  would have to complete its analysis of the bill. These two processes would be intertwined since the  parliamentarian uses the CBO score to assess whether bill meets the standards of the Byrd Rule, which requires any bill considered under budget reconciliation to directly pertain to federal spending or revenue.   


    The bill would require Senate Majority Leader Mitch McConnell's confidence that the required 50 votes were there to pass the bill. Given the failure of previous repeal efforts, he would not be willing to risk the political capital on another effort doomed to failure.  


    Again, all eyes would be on persuadable Republicans, such as Senator Susan Collins of Maine, Senator Lisa Murkoswski or Alaska, and Senator John McCain of Arizona, who did not assent to the previous legislation intended to repeal the ACA.  It was to be seen if they would hold their previous positions with regard to the Graham-Cassidy legislation.  


    With McCain making some positive remarks about the bill, along with his closeness to Senator Graham, it was possible that he could flip to supporting the bill.  


    Attention was also on Collins and Murkowski to see if they would again be holdouts on this newest incarnation of the Obamacare "repeal and replace" effort.  According to analysis by Axios, with Alaska and Maine being two of the states to suffer from stripped funding in Graham-Cassidy, it was quite likely Murkowski and Collins would hold steady with their objections to the Obamacare repeal effort.  Indeed, Collins telegraphed in the last week of September 2017 that it was "unlikely" she would support the Graham-Cassidy legislation. 


    Also at stake would be the question of whether or not Senator Rand Paul of Kentucky would maintain his objection to his bill, rooted in the belief that it did not go far enough to reverse Obamacare.  Rand Paul was not the only Republican objecting to the legislation on the basis of the claim that it did not go car enough to reverse Obamacare.  Senator Ted Cruz also indicated he was inclined to vote against the bill, noting that there needed to be more focus on consumer freedom. 


    Note that as September 2017 enetered its final week, Republicans sought to "sweeten" the proverbial pot for key holdouts.  First, a special provision was dangled in front of Murkowski to allow Alaska to retain its access to Obamacare benefits in exchange for her vote to kill the program nationally.  The move garnered harsh criticism from Democrats who argued that it was absurd to argue that Obamacare was so bad that it had to be ended, while conceding it was good enough to be offered as an effective bribe to Murkowski in Alaska.  Meanwhile, in a revamped version of the Graham-Cassidy bill, adjustments were made to ensure Arizona, Alaska, and Maine would actually benefit (rather than be depleted) in terms of federal block grant funds.  It was to be seen if these "incentives" would cause the three senators to sign onto the Graham-Cassidy repeal and replace effort. 


    Senator John McCain was the first Republican to announced that he was a "no" vote on the Graham-Cassidy bill, noting that the very same objections he had previously articulated on the floor of the Senate remained in place.  He  maintained his previously articulated objections to legislation that had not gone through proper procedures or bipartisan consideration. Once again, he called for a return to regular order and a bipartisan process aimed at achieving a health care resolution.   


    Meanwhile, the Congressional Budget Office (CBO) was unable to conduct a complete review of the proposal, given the compressed time period.  However, in preliminary analysis, the CBO warned that millions fewer Americans would have health insurance under Graham-Cassidy.


    Soon after the CBO's preliminatry findings were released, Senator Collins announced that she was opposed to the new Obamacare repeal legislation.  In a detailed letter in which she explained her "no" vote, Collins cited three concerns in the Graham-Cassidy proposal to turn Obamacare’s funding into a block grant as follows: (1) cuts to Medicaid; (2) rolling back protections for people with preexisting conditions; and (3) explicit opposition by leading health care groups on the basis of expectation that the bill would lead to higher premiums and millions of people being thrown off health coverage. 


    But Collins also addressed the last minute efforts by Republicans to try to -- at best, persuade, and at worst, compel -- her to vote in lockstep with other members of her party.  She explained why efforts to "sweeten the deal" for certain states was not something that should be regarded with seriousness as follows:


    "There has been some discussion that the new version of the bill includes additional money for my home state of Maine. The fact is, Maine still loses money under whichever version of the Graham-Cassidy bill we consider because the bills use what could be described as a “give with one hand, take with the other” distribution model. Huge Medicaid cuts down the road more than offset any short-term influx of money. But even more important, if Senators can adjust a funding formula over a weekend to help a single state, they could just as easily adjust that formula in the future to hurt that state. This is simply not the way that we should be approaching an important and complex issue that must be handled thoughtfully and fairly for all Americans."


    Note that on Sept. 26, 2017, it was announced that the Republicans did not have the votes to pass the Graham-Cassidy repeal and replacement bill.  As such, there would be no vote going forward in the near future.  That being said, President Donald Trump on Sept. 27, 2017 said that a new vote on health care would ensue in early 2018 instead. 



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