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- 07/11/17--07:06: _Republicans want to...
- 07/11/17--10:59: _The 'explosive' Don...
- 07/11/17--11:06: _MCCONNELL: August r...
- 07/12/17--10:09: _Senators are search...
- 07/12/17--13:12: _TRUMP: If Congress ...
- 07/13/17--06:04: _The new GOP healthc...
- 07/13/17--06:57: _HEALTHCARE EXPERT: ...
- 07/13/17--07:50: _Republicans are rel...
- 07/13/17--10:35: _The new Senate heal...
- 07/13/17--12:32: _The revised Senate ...
- 07/13/17--13:57: _'Unacceptable': Doc...
- 07/13/17--14:21: _TRUMP: 'The only th...
- 07/14/17--05:19: _Trump pressures GOP...
- 07/14/17--06:41: _GOP Sen. Lindsay Gr...
- 07/14/17--11:18: _The Republican heal...
- 07/14/17--13:29: _Virginia's governor...
- 07/14/17--19:21: _Here's what the CEO...
- 07/15/17--18:36: _John McCain's recov...
- 07/16/17--05:29: _Mitch McConnell is ...
- 07/17/17--08:53: _The Republican heal...
- 07/11/17--11:06: MCCONNELL: August recess postponed for 2 weeks
- Keep some of Obamacare's taxes: The new version could preserve the 3.8% investment income tax on people making over $200,000 a year, a huge source of revenue from Obamacare and one of the biggest reasons Republicans wanted to repeal the law. Other taxes including one on health insurance executives and Medicare health insurance tax would no longer be repealed in this version. This move would not sit well with conservatives and anti-tax advocates.
- Increased funding for the opioid crisis: The original bill had $2 billion in funding to combat the opioid crisis. The new version is expected to increase that number to around $45 billion.
- A modified Cruz amendment: A modified version of the Cruz amendment will be in the bill. According to the talking points, if an insurer offers a plan on the individual insurance exchanges that qualifies with all of Obamacare's regulations, they can also offer plans off the exchange that do not adhere to those regulations. Additionally, the bill will include a fund to offset costs for insurers who sign up "high risk individuals" to the off-exchange, de-regulated plans.
- Allow people to use tax credits on catastrophic health plans: These high-deductible plans provide skinny coverage with three p xx. Under Obamacare, tax credits from the federal government were not allowed to be used on these plans since they did not adhere to the minimum standards for coverage.
- Increased funding for the state stability fund: This fund is distributed to states to help bring down premiums and start programs that lower costs for insurers and consumers. According to reports, there will be $70 billion of new money for this fund in the new version of the BCRA in addition to the $112 billion in the first version.
- Allow people to spend money from health savings accounts on premiums: HSAs, which are not taxed, can be spent on a variety of medical care costs. A new provision would allow it to go toward insurance costs.
- Susan Collins (NO):Collins tweeted soon after the release of the updated BCRA that she would not support a motion to proceed: "Still deep cuts to Medicaid in Senate bill. Will vote no on MTP. Ready to work w/ GOP & Dem colleagues to fix flaws in ACA."
- Rand Paul (NO): A longtime critic of the bill, Paul said soon after the update came out that he would not vote for the motion to proceed.
- Rob Portman (UNDECIDED): Portman's office confirmed he was reviewing the bill and would wait for a score from the Congressional Budget Office. His chief concern is deep cuts to Medicaid funding proposed in the bill.
- Lisa Murkowski (UNCLEAR): Despite a substantial funding proposal for Alaska in the newest version of the BCRA, Murkowski remains on the fence. The senator has taken issue with the BCRA's cuts to Medicaid and the freeze of funding to Planned Parenthood. Murkowski was seen meeting with McConnell and Sens. Dean Heller and Shelley Moore Capito after the bill's release.
- Dean Heller (UNCLEAR): Heller, who is up for reelection in 2018 in Nevada, a state Hillary Clinton won, has concerns about the Medicaid cuts.
- Shelley Moore Capito (UNCLEAR): Capito has expressed similar concerns about potentially slashed Medicaid funding.
- Mike Lee (UNDECIDED): Lee supported an amendment from Sen. Ted Cruz that would allow insurers to sell plans that did not comply with the Affordable Care Act's regulations. The modified version included in the newest BCRA version did not immediately get Lee on board. "Just FYI — The Cruz-Lee Amendment has not been added to BCRA. Something based on it has, but I have not seen it or agreed to it," Lee tweeted. "I am withholding judgment and look forward to reading it."
- Making sure there aren't lifetime caps, which could prevent people from getting care after they use a certain amount of benefits. This can be an issue especially for those with rare diseases, because treatments tend to be more expensive. Some of Shire's drugs, for example are among the most expensive by list price in the US.
- Ensuring children keep coverage even if their parents change jobs.
- And, less directly related to changes to the ACA, an increased transparency around getting access to medicine, "so that they don't have to have a maze of Byzantine things to go through which makes it frustrating for families," Ornskov said. "
Almost every year, Congress spends the dog days of August away from Capitol Hill enjoying a month-long recess to return to their districts and spend some time away from Washington.
But this year, with the Republican healthcare bill and many big-ticket agenda items hanging in the balance, some GOP lawmakers are calling for leadership to shave off their break to try to push through some of the legislation.
A group of 10 Republican senators, led by Sen. David Perdue of Georgia, sent a letter to Senate Majority Leader Mitch McConnell on June 30 asking him to shorten or cancel the August recess if more progress wasn't made on several issues, including the healthcare bill.
"Our current Senate calendar shows only 33 potential working days remaining before the end of the fiscal year," the senators said. "This does not appear to give us enough time to adequately address the issues that demand immediate attention. Therefore, we respectfully request that you consider truncating, if not completely foregoing, the scheduled August state work period, allowing us more time to complete our work."
The group of senators plans to again ask for a truncated recess during a press conference Tuesday.
The effort has gained steam in recent days as the Senate GOP healthcare bill seems stuck in place.
Sen. Ted Cruz, who is pushing for an amendment to add to the Better Care Reconciliation Act, told Fox News' Sean Hannity on Monday that he doesn't think the Senate should go on recess until the healthcare bill is finished.
"It’s crazy that we would be taking a recess,"Cruz said. "There are a bunch of us, myself included, that have been urging leadership back from January not to take any recesses."
"Let’s work every day, let’s work weekends, let’s work until we get the job done,"the Texas senator added.
On the House side, Rep. Mark Meadows, the leader of the influential conservative House Freedom Caucus, also called for the August recess to be shortened to work on legislative items like the debt ceiling, avoiding a government shutdown, and tax reform.
The White House backed up these efforts on Monday, with President Donald Trump advocating for lawmakers to stick around Washington.
"I cannot imagine that Congress would dare to leave Washington without a beautiful new HealthCare bill fully approved and ready to go!" Trump tweeted early Monday.
And Ronna Romney McDaniel, the chair of the Republican National Committee, told Breitbart in an interview Monday that the break should be slashed.
"It’s not easy, there’s a lot of diversity of thought, we’re having a dialogue and discussion, I do think it’s critical we find a resolution and I agree with the President that Congress should not take an August recess until they figure out the repeal and replacement of Obamacare," McDaniel said.
The focus of Senate Republicans this week was supposed to be on passing their healthcare bill. But bombshell developments in the controversy surrounding Russia's election meddling could get in the way of those plans, analysts say.
The release on Tuesday of email exchanges involving Donald Trump Jr. and a music publicist — who arranged for him to meet with a Russian attorney who the publicist said would provide damaging information about Hillary Clinton — could be another roadblock for Republicans' agenda.
Policy analysts say the revelations are likely to slow — if not derail — the push to pass a healthcare bill, along with progress on other items like tax reform.
Greg Valliere, the chief strategist at Horizon Investments, said the emails marked an important turning point in the investigations into whether the Trump campaign colluded with Russian operatives to meddle in the 2016 election.
"This is explosive — Donald Trump Jr. has admitted that he took a meeting with someone he apparently thought was a foreign agent who could affect the election," Valliere said in an email to Business Insider. "So the word 'collusion' now becomes more credible."
Isaac Boltansky, an analyst at the political-research firm Compass Point, said that "each drip of news from the Russian investigation" made it less likely Republicans would be able to maintain political momentum.
"Some will view this meeting revelation as the smoking gun, while others will view it as nothing more than the realities of modern politics," Boltansky said. "Either way, our message to clients is that the total tonnage of questions will have an impact on both congressional GOP support for the White House and the broader legislative agenda."
The revelations come at a particularly damaging time, said Chris Krueger, an analyst at Cowen Washington Research Group, because Republicans are attempting to make serious progress on their healthcare bill and other legislation before the August recess.
Republicans were hoping to make headway on raising the debt ceiling and passing a funding bill for the government before the recess, which Senate Majority Leader Mitch McConnell on Tuesday delayed until the third week of August.
The Russia investigations now appear to be "closer to completion" than either healthcare reform or tax reform, Krueger said.
"This is the most important three-week legislative sprint of the Trump presidency, and the multiple Russia investigations seem to be far further downfield than the mysterious tax-reform unicorn, to say nothing of the legislative Vietnam that is healthcare," Krueger said in an email to Business Insider.
Valliere said Republicans' ability to accomplish various goals would come down to just how much they stick by President Donald Trump and how many see the controversies as an impediment.
"The key is Republicans, most of whom are fed up with Trump," Valliere said. "They're in no mood to do him any favors, so this makes it even more difficult for the president to pass his agenda. Health reform is on life support, the budget will be a free-for-all, and tax reform almost certainly will not pass this year."
For an agenda already hitting roadblocks, this is another unnecessary headache, analysts say.
"The Russian scandal has gone from very serious to extremely serious, and it's a clear negative for Trump's agenda on Capitol Hill," Valliere said.
Senate Majority Leader Mitch McConnell on Tuesday said he would delay the start of the Senate's typically monthlong August recess by two weeks to try to finish work on the GOP healthcare bill and other legislative items.
McConnell pinned part of the blame on Democrats' obstruction, a talking point the White House and Republican lawmakers have amplified in recent weeks.
"In order to provide more time to complete action on important legislative items and process nominees that have been stalled by a lack of cooperation from our friends across the aisle, the Senate will delay the start of the August recess until the third week of August," McConnell said in a statement.
The Senate healthcare bill, the Better Care Reconciliation Act, has stalled as members from the conservative and moderate wings of the GOP are unable to come to an agreement on key elements.
Several Republican senators had called for the delay of the August recess to finish work on the BCRA and other items like raising the debt ceiling and funding the government. A group of 10 GOP lawmakers led by Sen. David Perdue of Georgia wrote a letter on June 30 asking for a delay.
The group applauded the choice in a statement from Perdue's office on Tuesday.
"We are glad leadership took our concerns into consideration," it said. "It is time to get results for the American people."
The conservative House Freedom Caucus, which has pushed for the House to delay its recess also, echoed that sentiment in a statement after the announcement.
"We applaud Senate Majority Leader Mitch McConnell's decision to keep the Senate in session in August to accomplish the important work of the American people," it said. "We call on House leadership to do the same. There are too many unresolved issues before Congress including tax reform, health care, the debt ceiling, government funding, and more to leave Washington before the people's work is done."
While talking to reporters after the announcement, McConnell said a revised version of the BCRA would be released Thursday and that a vote would come next week. The majority leader also said the debt ceiling could be addressed in the first two weeks of August. According to the Congressional Budget Office, the debt ceiling will be breached sometime in mid-October.
Here's the full statement from McConnell:
"Once the Senate completes its work on health care reform, we will turn to other important issues including the National Defense Authorization Act and the backlog of critical nominations that have been mindlessly stalled by Democrats.
"In order to provide more time to complete action on important legislative items and process nominees that have been stalled by a lack of cooperation from our friends across the aisle, the Senate will delay the start of the August recess until the third week of August."
The prospects for the Senate healthcare bill are dimming despite attempts by Majority Leader Mitch McConnell to bring skeptical Republican lawmakers on board, and some members are looking toward what comes next.
McConnell told reporters Tuesday that leadership will roll out a revised version of the Better Care Reconciliation Act (BCRA) on Thursday with the target of voting on the bill next week.
But even with the new timeline, the GOP conference does not appear any closer to resolving the issues that have held up the bill.
On one side, conservatives are pushing for further rollbacks to the regulatory structure of the Affordable Care Act, or Obamacare.
Sen. Rand Paul, in a Breitbart op-ed published Wednesday, said the BCRA keeps too much of Obamacare and betrays the GOP's promise to repeal the law.
"Shame. Shame on many in the GOP for promising repeal and instead affirming, keeping, and, in some cases, expanding Obamacare. What a shame,"Paul wrote.
Sens. Ted Cruz and Mike Lee have proposed an amendment to the bill that would allow insurers to sell plans that are not compliant with two major Obamacare regulations. But since all elements of the legislation must deal with deficit reduction because of the process by which Republicans are moving the bill, the Senate parliamentarian could prohibit the amendment from being added.
If it is not added, both Lee and Cruz have said they will not support the bill.
Moderates, on the other hand, are not convinced that the BCRA includes enough protections for poorer and older Americans. Concerns remain about rollbacks for Medicaid funding and subsidies to purchase insurance in the BCRA.
Sen. Susan Collins of Maine remains a serious centrist skeptic of the bill and said possible changes haven't been sufficient to win her over yet.
"I do need a complete overhaul to get to a yes," Collins told reporters Tuesday.
Other senators like Dean Heller, Lisa Murkowski, Shelley Moore Capito have expressed similar misgivings.
While there have been some concessions added to the bill to appeal to more moderate members, according to reports, the bill remains largely intact from its initial draft version, and it's questionable whether it can win over holdouts from either side.
Sen. Chuck Grassley told Politico on Tuesday he ws "very pessimistic" about the prospects for the bill, while Sen. John McCain said Republicans are "in gridlock."
Some GOP senators are mulling the idea of a plan B: a bipartisan solution.
Bloomberg's Sahil Kapur and Laura Litvan reported Wednesday that a group of Democrats and moderate Republicans met over the past few days to discuss a possible bipartisan solution that would shore up the Obamacare markets.
Sen. Lindsay Graham told reporters he was working on a counter-proposal for healthcare that he believes could get the support of some Democratic senators and governors.
And Sen Ron Johnson — a conservative skeptic on the BCRA — told Bloomberg that it might be time to "bite the bullet" and pass a bill that would stabilize the Obamacare markets.
The possible shift comes after several Republicans mentioned the possibility of working with Democrats if the BCRA failed over the week-long July 4 recess — including McConnell.
It could also be a popular solution to what has so far been an unpopular healthcare process. A Morning Consult/Politico poll released Wednesday found 54% of Republican voters want lawmakers in their party to work with Democrats on a healthcare solution, while just 38% want the GOP to continue on its current more partisan path.
President Donald Trump said in an interview published Wednesday that he would be "angry" with congressional Republicans failed to get a bill that would repeal and replace Obamacare to his desk.
In an interview with the Christian Broadcasting Network's Pat Robertson, Trump was asked what would happen if Congress was unable to pass a bill to overhaul the healthcare system.
"I will be very angry about it and a lot of people will be very upset," Trump said. "But I'm sitting waiting for that bill to come to my desk. I hope that they do it. They've been promising it for years."
The president said now is the time for repeal, since the GOP controls the White House and Congress.
"Now we have a president that's waiting to sign it," Trump told Robertson. "I have pen in hand so now it means something. You know, those other times, those many, many times, that they passed it, it didn't mean anything."
Trump also pressured Republican senators specifically. Senate Republicans are attempting to move their legislation, the Better Care Reconciliation Act, but it has become a source of major division within the party and it is unclear whether it can pass.
"We have 52 senators," Trump said. "It's very hard to get. ... We need almost all of them. You need almost all of them and that's the hold up. And states are somewhat different. But with all of that being said, it has to get passed. They have to do it."
Senate Majority Leader Mitch McConnell said he will release an updated version of the BCRA on Thursday and is aiming for a vote on the updated bill sometime next week.
"He's got to pull it off. Mitch has to pull it off. He's working very hard. He's got to pull it off," Trump said of the Majority Leader.
The nonpartisan Congressional Budget Office estimated that the BCRA would leave 22 million more Americans without health insurance in 2026 compared to the current baseline. Additional analysis estimated that out-of-pocket-costs and premiums would increase under the BCRA, as well.
Watch a portion of the interview:
Republicans in the Senate are set to release an update of their healthcare bill as they work to find a way to repeal and replace the Affordable Care Act.
One attempt to attract conservative holdouts to the new version of the Better Care Reconciliation Act will be the addition of a provision introduced by Sen. Ted Cruz and supported by fellow Republican Sen. Mike Lee.
The amendment would allow insurers to provide plans that do not comply with two major regulations of the ACA: community rating and essential health benefits. Cruz and Lee have pushed it as a way to bring down premiums and open up choice in the individual market.
According to reports from Politico and Axios, the newest version of the bill will include the plan when it is released Thursday. The reports also suggest the language will be in brackets, meaning it is subject to further edits.
But the plan drew backlash Wednesday from an influential group of insurers worried about the potential effects of such a provision on people with preexisting conditions. According to these groups, it could make more robust coverage that sick people need prohibitively expensive and possibly force some of the sickest out of the market altogether.
But an analysis by the Kaiser Family Foundation, a nonpartisan health-policy think tank, said the amendment could cause the cost of plans that complied with those regulations to skyrocket, as only those who were sick and needed the more generous coverage would buy them.
"The ACA-compliant plans would effectively become a high-risk pool, attracting enrollees when they need costly health benefits — such as maternity care, or drugs to treat cancer or HIV, or therapies to treat mental health and substance abuse disorders — and those with pre-existing conditions who are turned down by non-compliant plans or charged high premiums based on their health. By contrast, non-compliant plans would attract healthier consumers, at least as long as they didn't need coverage for such benefits. Premiums from the healthier enrollees would not be pooled to help keep the price of compliant plans affordable."
Based on the number of people with preexisting conditions who were subject to rejection by insurers before the ACA, that could leave as many as 1.5 million people in the nongroup market with prohibitively expensive plans, according to the analysis by Kaiser.
The provision also drew a rebuke from American Health Insurance Plans, a lobbying organization that represents some of the US's largest insurers. The AHIP said the Cruz proposal would create "an un-level playing field" and "unstable health insurance markets."
"This is particularly true for patients with preexisting conditions — who would be most affected and potentially lose access to comprehensive coverage and/or have plans that were far more expensive, as premiums in the Exchange market would rise much faster than under existing market conditions and insurance options dwindle," the group said in a statement Wednesday.
The Cruz provision could eventually be stripped out for political reasons or because it does not qualify under the Senate's rules. The BCRA is being advanced through a process known as budget reconciliation, which allows Republicans to avoid a filibuster from Democrats but means everything in the bill must affect the federal budget deficit. If the Cruz addition does not qualify, per the Senate rulekeeper, it would be removed.
Republican Sen. Chuck Grassley of Iowa said the amendment was a "subterfuge to get around pre-existing conditions," and other moderates have said they will not support a bill that includes the idea.
At the same time, Cruz and Lee have suggested they will not support the legislation if the idea is dropped, a potentially crippling blow to its chances of passage.
Sherry Glied, Dean of New York University's Robert F Wagner Graduate School of Public Service, and former assistant secretary for planning and evaluation at the Department of Health and Human Services, explains some of the issues in the Obamacare exchanges and how the Trump administration may have contributed to what they call a "death spiral." Following is a transcript of the video.
DR. SHERRY GLIED:When you think about whether Obamacare is collapsing, I think you really have to sort of think about the current situation and the counterfactual.
Would it naturally collapse? Or is it collapsing in part because the administration is causing it to collapse?
Premiums last year – that is, coming into this year's cycle – increased quite a lot.
There are a couple of things the administration has done that may be contributing to weak performances of the exchanges. The first thing is that almost the first thing that President Trump did when he entered office is to put out an executive order saying that they would not be strenuously enforcing the individual mandate. So, that likely led to some reduction in signups.
They also turned off the marketing spigot a little bit earlier this year than had been done in prior years.
But, the most important concern, I think, in terms of the stability and future of these markets is that they are supposed to have a stream of money come in to pay for reductions in the cost sharing for low-income subscribers. So, the way that the Affordable Care Act is set up, if you're a low-income person and you buy a health plan, that health plan gets an extra subsidy so that your deductibles, your cost sharing, what you have to pay when you go to the doctor, isn't too high.
There's been an argument between the Republican Congress and President Obama, when he was still in office, about whether the money that was flowing under that piece of the legislation had correctly followed Congressional rules.
But, President Trump has not been clear about whether he will let those payments flow or not. If the payments don't flow, insurers will be responsible for giving better coverage to low-income people, but they won't be subsidized for that.
And they're building that into their premiums, and raising them accordingly.
Senate Republican leadership is set to roll out the updated version of its healthcare bill on Thursday, but continued pushback from its own conference likely puts the legislation in the same perilous position as previous iterations.
The new version of the Better Care Reconciliation Act (BCRA), will be released by Senate Majority Leader Mitch McConnell during a meeting of the Republican conference around 11:30 a.m. ET.
Several reports have outlined the changes to the bill that attempt to bring the conference together in agreement. The details of the bill, sent to lobbyists ahead of the meeting, outline a variety of edits to the bill but indicate that much of the original BCRA is intact.
Here's a rundown of what changes may be in the new version of the BCRA:
While many of these changes address some concerns of GOP members, they likely won't have a big impact on the overall impact of the bill according to experts.
"If the reported details of the revised Senate bill are right, it's hard to see how it alters much the 22 million increase in the uninsured," tweeted Larry Levitt, a senior vice president at The Kaiser Family Foundation, a nonpartisan health policy think tank.
The score from the Congressional Budget Office estimated the first version of the BCRA would result in 22 million more uninsured Americans by 2026 than under the current system.
The new version may not win Republican hold outs over
The biggest issue of concern: The new legislation reportedly does not address an approximated $772 billion in cuts to the Medicaid program through 2026. For many moderate detractors in states with large Medicaid populations, that could be a make or break issue.
Sen. Lisa Murkowski of Alaska has blasted the cuts, which would roll back Obamacare's Medicaid expansion and cap the amount of funding the federal government provides.
"The ACA allowed for Medicaid expansion. The ACA didn't address traditional Medicaid. … Why do we not focus on the urgency of the concerns with the ACA?" Murkowski told reporters Wednesday, according to Politico.
Other moderate senators like Susan Collins of Maine, Shelley Moore Capito of West Virginia, and Dean Heller of Nevada also expressed concerns about the new version preserving most of the Medicaid cuts.
On the other end of the GOP spectrum, conservative-leaning members have remained on the fence about their intentions.
Sen. Rand Paul of Kentucky told reporters during a conference call Wednesday that he would not support the bill even after the changes. Paul criticized the "kitchen sink" approach McConnell has taken to win over members by adding new spending to the legislation.
Instead, said Paul, the GOP should "narrow" the bill to a slim partial repeal of Obamacare, addressing the parts the on which the conference could agree.
And an amendment offered by Sen. Ted Cruz that would allow insurers to dodge certain regulations created by Obamacare will be tentatively added to the bill. That will likely help the legislation earn the support of Cruz and Sen. Mike Lee, but it could also help push moderates to oppose the legislation. On Wednesday, a group featuring some of the US's largest insurers blasted the Cruz amendment, highlighting its potential effects on protections for people with preexisting conditions.
Majority Whip John Cornyn, the No. 2 Republican in the Senate, told reporters on Wednesday night that the bill does not have enough votes to pass. It can only lose two Republican votes. As of now, none of the 10 senators that came out publicly against the original version of the bill said they have moved into the "yes" column.
The text of the newest version of the Senate healthcare bill contains a provision aimed at one Republican holdout: Sen. Lisa Murkowski.
The Alaska senator would see a guarantee of funding for her state to combat high premiums, in a clear attempt to win over the senator who has been vocal in opposition to various elements of the bill.
The provision has to do with the state stability fund, a pot of money that would be given to states to help deal with high insurance premiums and encourage people to sign up for coverage.
Here's the piece pertaining to Alaska (emphasis added):
"The Administrator shall determine an appropriate procedure for providing and distributing funds under this subsection that includes reserving an amount equal to 1 percent of the amount appropriated under paragraph (1) for a calendar year for providing and distributing funds to health insurance issuers in States where the cost of insurance premiums are at least 75 percent higher than the national average."
A report from the Department of Health and Human Services showed that pre-tax credit premiums in the 39 states with federal-run individual marketplaces under the Affordable Care Act will average $476 a month in 2017. In Alaska, the average monthly cost for premiums is an average of $1,041 for 2017, more than twice the national average.
No other state would qualify for the 75% higher than average provisions, based on the HHS report.
Based on the amount of money set aside through the state stability fund, Alaska would likely end up with hundreds of millions of dollars annually toward its health insurance markets.
But even with the addition, Murkowski's support for the legislation remains in question. She has also expressed opposition to the cuts to Medicaid and a freeze in funds for Planned Parenthood, neither of which changed from the original version.
Skeptical Republican senators bristled at the newly updated version of the Senate healthcare bill released Thursday morning, putting its future in doubt.
Almost immediately, two Republican senators came out against a procedural vote that would get the bill to the floor, meaning Senate Majority Leader Mitch McConnell and GOP leaders cannot afford to lose another vote.
A third GOP defection would prevent the bill from even being considered by the broader Senate and would most likely require the Better Care Reconciliation Act to be substantially overhauled — or scrapped.
Here's a rundown of the senators to watch in the debate and their current status on the vote:
Doctors and patient groups still aren't happy with the updated version of the Better Care Reconciliation Act that Senate Republicans released Thursday.
The groups, including the American Academy of Pediatrics, the American College of Physicians, and American Hospital Association, are critical of Republican efforts to repeal and replace the Affordable Care Act, better known as Obamacare.
Among the changes to the new bill are that more funds will be set aside for the opioid crisis, and a provision that would allow people to pay for premiums using a health savings account. The update also includes an amendment from Sen. Ted Cruz and Sen. Mike Lee that critics say could make plans with adequate coverage unaffordable to those who have certain medical conditions.
The updated bill, like one passed by the House of Representatives, rolls back many of the provisions of Obamacare, including taking deep cuts from the Medicaid program.
Here's what the groups thought of the bill
The American Academy of Pediatrics, which represents 66,000 pediatricians, opposed the BCRA the first time around, citing the changes to Medicaid.
"The bill includes misleading 'protections' for children by proposing to exempt them from certain Medicaid cuts," Dr. Fernando Stein, president of the AAP, said in a statement in June. "A 'carve-out' for children with 'medically complex' health issues does little to protect their coverage when the base program providing the coverage is stripped of its funding."
After the updated draft was released, the tone was the same. "The new Senate bill still fails children," the organization tweeted.
The American Lung Association wasn't happy with the impact of the revised bill on preexisting conditions.
The American Heart Association, along with American Cancer Society Cancer Action Network, American Diabetes Association, American Lung Association, Cystic Fibrosis Foundation, March of Dimes, Muscular Dystrophy Association, National Health Council, National Organization for Rare Disorders, WomenHeart: The National Coalition for Women with Heart Disease came out with a joint statement against the revisions, specifically the Cruz amendment.
"Under the amendment, insurance companies would be allowed to charge higher premiums to people based on their health status—in addition to opting out of other patient protections in current law, such as the guarantee of essential health benefits and the prohibition on annual and lifetime coverage caps. Separating healthy enrollees from those with pre-existing conditions will also lead to severe instability of the insurance market. This is unacceptable for our patients."
The American Hospital Association, which represents thousands of hospitals and health systems, still wasn't happy with the cuts to the Medicaid program.
"Unfortunately, in the latest update released today, the unacceptable flaws of BCRA remain unchanged, and there are no significant changes to the massive Medicaid reductions," AHA President Richard Pollack said in a statement on Thursday.
President Donald Trump said he believes reforming the US healthcare system is harder than solving one of the most prolific conflicts in the Middle East.
During a question-and-answer session on Air Force One during a flight to France on Thursday, Trump turned his attention to healthcare reform — which is currently toiling in Congress — and compared it to the peace process between Israel and Palestine.
"We have a thing called healthcare,"Trump said."I'm sure you haven’t been reading about it too much. It is one of the — I'd say the only thing more difficult than peace between Israel and the Palestinians is healthcare."
The Senate version of the GOP healthcare bill has been slowed by disagreement between the conservative and more moderate wings of the party, even after an updated version of the legislation was released Thursday.
Conservatives believe the bill does not go far enough to repeal Obamacare. Moderates, on the other hand, say its cuts to programs like Medicaid would be too harmful.
Trump acknowledged these difficulties during the talk with reporters.
"It’s like this narrow road that about a quarter of an inch wide," Trump said. "You get a couple here and you say, great, and then you find out you just lost four over here. Healthcare is tough."
As of now, it is unclear whether the Senate healthcare bill, the Better Care Reconciliation Act (BCRA), has enough support among Republicans to get past a key procedural vote— much less a full floor vote.
President Donald Trump on Friday used Twitter to try to pressure members of his party to pass healthcare legislation, shooting off the messages just moments before attending a Bastille Day parade in France.
"After all of these years of suffering thru ObamaCare, Republican Senators must come through as they have promised!" Trump tweeted.
Senate Republican leadership released the updated draft of its healthcare bill, the Better Care Reconciliation Act, on Thursday. The draft was little changed from the original version released two weeks ago, but some tweaks were aimed at winning over conservative members.
Two GOP lawmakers, however, have already said they will not vote yes on a key procedural measure next week. One more defection would sink the bill, which has no support from Democrats.
Trump, who campaigned on a promise to repeal Obamacare, the healthcare law officially called the Affordable Care Act, urged the lawmakers to send him a bill to sign.
"Republicans Senators are working hard to get their failed ObamaCare replacement approved," Trump said. "I will be at my desk, pen in hand!"
A group of moderate lawmakers have taken issue with deep proposed cuts to the federal Medicaid program, an issue that was not addressed in the newly updated BCRA.
For the bill to pass, Senate Majority Leader Mitch McConnell needs to win over some of those moderate skeptics, a fact Trump alluded to in his tweets.
"So impt Rep Senators, under leadership of @SenateMajLdr McConnell get healthcare plan approved," Trump tweeted. "After 7yrs of O'Care disaster, must happen!"
Trump also commended Vice President Mike Pence for leading the White House efforts on the bill during Trump's visit to France over the past two days.
".@VP Mike Pence is working hard on HealthCare and getting our wonderful Republican Senators to do what is right for the people," Trump said.
The New York Times' Maggie Haberman reported that the last in the series of tweets came just before Trump stepped out of his motorcade to attend the Bastille Day celebration in Paris with French President Emmanuel Macron.
POTUS is tweeting about Pence while stepping out of his limo. Whatta town!— Maggie Haberman (@maggieNYT) July 14, 2017
Republican Sen. Lindsey Graham has drafted an alternative to the updated Senate healthcare bill unveiled Thursday — one that could redirect the debate if the Better Care Reconciliation Act fails to win sufficient GOP support.
Graham's proposal would send about $500 billion of the Affordable Care Act's federal funding directly to the states, giving governors and state legislatures more control over how much of the Obama-era law it preserves.
Graham is marketing his proposal, which would allow states to replace Obamacare, make tweaks to the 7-year-old law, or keep it entirely in place, as an Obamacare replacement to Republicans and an Obamacare repair to Democrats.
"Instead of having a one-size-fits-all solution from Washington, we should return dollars back to the states to address each individual state's health care needs," Graham said in a Thursday press release.
"Just like no two patients are the same, no two states' health care needs are the same," he continued. "A solution that works in California may not work in Virginia. These funds are already being spent on Obamacare, but instead of having Washington decide, we'll empower each individual state to choose the path that works best for them."
Republican Sens. Bill Cassidy and Rick Santorum are working with Graham on the bill, which is expected to be offered as an amendment to the Better Care Reconciliation Act next week. The proposal is modeled on the 1996 Welfare Reform Act, which redirected federal funding to the states through block grants.
"We're going to support Mitch's effort with his new plan, but we want an alternative and we're going to see which one can get 50 votes," Graham said, referring to Senate Majority Leader Mitch McConnell. "We're not undercutting Mitch, he's not undercutting us."
While the Senate healthcare bill, the Better Care Reconciliation Act (BCRA), faces a plethora of political obstacles, one of its biggest tests will come Monday.
That's the day GOP leaders expect the Congressional Budget Office to release its updated score for the legislation.
The previous edition of the CBO score was a huge sticking point for moderates, and Democrats pounded the unflattering conclusions.
The CBO projected that 22 million more Americans would be without health insurance in 2026 under the BCRA compared to the current system. It also predicted that many people would end up paying higher out of pocket costs and face significant financial burdens, offsetting the lower premiums.
According to experts, it is unlikely that the CBO score will budge much based on the revisions released on Thursday.
"I don't see a lot here that would meaningfully change the CBO score. We're still likely to see many millions of people losing or going without coverage as a result of this bill," Cynthia Cox, an associate director at the Kaiser Family Foundation, a nonpartisan health-policy think tank, told Business Insider. "Although some of the taxes on wealthy people are retained, the bill doesn't appear to use much of that to cover low-income people."
Matthew Fiedler, a fellow at the Brookings Institution, agreed that coverage losses would still be massive.
"This is still a bill that will result in very large reductions in insurance coverage and reductions in the quality and affordability of the insurance coverage for many people who retain coverage," Fiedler told Business Insider.
There is some question as to what exactly the score released Monday will include. Additional language based on an amendment offered by Sen. Ted Cruz may not be part of the CBO score, since it was added later in the process. If that's the case, the score may not present a full picture of the legislation.
The Trump administration's repeated attempts to discredit the CBO intensified over the past week with a social media video attacking the office's projections.
Virginia Gov. Terry McAuliffe took a shot at Vice President Mike Pence on Friday while introducing him at the National Governors Association's summer meeting, praising Pence for expanding Medicaid as the governor of Indiana.
"I thank Vice President Pence — he showed true backbone himself in Indiana when he expanded Medicaid for his citizens," McAuliffe, a Democrat and the chairman of the NGA, told the audience gathered in Rhode Island. "So he understands the challenges that we as governors face to make sure we're providing that quality care."
Pence, who was one of 10 Republican governors to expand Medicaid, the government's health-insurance program for low-income Americans, now supports the GOP's proposal to make significant cuts to the program included in a bill to replace Obamacare, the healthcare law officially called the Affordable Care Act. Thirty-two states expanded access to Medicaid under Obamacare, extending health coverage to more than 11 million Americans.
McAuliffe — who has been critical of the GOP's healthcare bill, the Better Care Reconciliation Act, which has not gotten any Democratic support — said Pence understood the importance of working across the aisle on key issues, including healthcare.
"He understands that we want to work together in a bipartisan way," he said. "We want to work together on infrastructure. We want to work together on tax reform. And we want to work together on healthcare, so that we can provide the best quality healthcare for our citizens."
Pence responded to McAuliffe's comments during his speech to the group.
"Let me speak to you as a former governor and as someone who, as Terry McAuliffe pointed out, I made the decision in Indiana to expand Medicaid under a waiver," Pence said. "You all know your states. You know your people. You know how to create the innovative solutions to address the unique healthcare needs of the people of your states."
Pence argued that the GOP plan would give governors the flexibility to "act on your own ideas" and emphasized his position that his party's bill "secures Medicaid for the neediest in our society," which he also tweeted on Friday afternoon.
The Congressional Budget Office projected in June that the BCRA would cut Medicaid spending by $772 billion by 2026.
But that doesn't mean drugmakers don't have skin in the game, or that they aren't doing anything to make sure they're represented.
For Flemming Ornskov, the CEO of $50 billion drugmaker Shire, that's meant pushing back against efforts to dismantle the parts of the Affordable Care Act that ensure patients get continuous and lifetime coverage.
Shire, which is headquartered in Dublin, counts on the US for as much as two-thirds of its annual revenue. It's known for making ADHD medicine, like Adderall and Vyvanse, and its focus on rare diseases like the blood disorder hemophilia, many of which affect people starting at an early age.
Ornskov said he's concerned about whether the legislation would make changes to how people with existing illnesses get coverage. In both the bill that passed the House and a revised version of the Senate bill, there is the possibility that people with so-called "preexisting conditions" might have a harder time getting affordable and comprehensive healthcare compared to otherwise healthy people.
As such, Ornskov said the company is spending lobbying efforts on pushing back on changes that could dismantle some of the key parts of the ACA. Specifically:
That transparency, in some cases, can be more critical than the issue of having insurance or not.
"Oftentimes it's not 'I'm covered or I'm not covered,'" Ornskov said about patients trying to get access to medication. "It is maneuvering in a system which is very complex." For example, patients might have to answer a lot of questions before insurance can sign off on a medication, or they might come across limitations to how much of a prescription they're allowed to have.
The Senate's vote to proceed to debate on Republicans' healthcare bill will be delayed due to Sen. John McCain's health issues, Senate Majority Leader Mitch McConnell said in a statement late on Saturday.
McCain's office announced he will be recovering from surgery next week in Arizona after having a blood clot removed from above his left eye.
"While John is recovering, the Senate will continue our work on legislative items and nominations, and will defer consideration of the Better Care Act," McConnell said in a statement.
The announcement had immediately thrown into question the fate of Senate Republicans' Obamacare repeal vote.
Lawmakers had said they hoped to hold a procedural vote next week to begin debate on the contentious healthcare bill, but McCain's absence would have complicated that plan.
In order to proceed, Republicans need 50 votes out of their 52-member Senate majority, with Vice President Mike Pence expected to break the tie.
Two Republican senators, Susan Collins of Maine and Rand Paul of Kentucky, have already said they will not vote to proceed, making McCain's "yes" vote essential.
Currently, there is a disagreement between moderates and conservatives over the bill. Moderates, like Collins, believe the cuts to Medicaid are too deep. While conservatives, like Paul, believe the bill does not go far enough in its repeal of Obamacare's regulations.
Collins has said she will not vote for a key procedural vote to bring the bill to the floor. Paul also said he will not vote for a procedural maneuver, called a motion to proceed.
This is the second time the bill, named the Better Care Reconciliation Act (BCRA), has been delayed. The first time was due to a lack of support for the bill and prompted the rewrites that were released Thursday.
McCain was expected to vote for the BCRA, despite making comments expressing concerns about various aspects of the bill.
In a statement on Friday, McCain criticized the quick process used for the BCRA, but said he would introduce amendments to assist people in Arizona.
"If we are not able to reach a consensus, the Senate should return to regular order, hold hearings and receive input from senators of both parties, and produce a bill that finally provides Americans with access to affordable and quality health care," he said.
McCain's office said in a statement Saturday he is in "good spirits and recovering comfortably at home with his family. Doctors at the Mayo Clinic Hospital in Arizona described the procedure as "minimally invasive" and said it went "very well."
Senate Majority Leader Mitch McConnell is known for his dealmaking and ability to deliver a bill over the objections of some of his members.
On healthcare, McConnell's had his work cut out for him: The House bill to replace the Affordable Care Act was widely panned by Republican senators and the public, he could afford to lose only two votes on the Senate's version of the bill, and he had to get it passed with a relatively short window.
Given those pressures, it's no surprise that the Senate GOP's bill, called Better Care Reconciliation Act (BCRA), is on its third iteration and still facing an uphill battle to pass.
Despite the tough road ahead, strategists say that McConnell's penchant for cutting deals may be enough to save the BCRA.
Since the start of deliberations on the Senate, leaders have promised to craft a more moderate bill than the House's American Health Care Act.
Given the parts of Obamacare that the BCRA kept — including its tax credit structure, slower phase out of Medicaid expansion, and funding to offset insurer costs — conservative groups took issue with the bill as too far to the center.
A former Senate GOP leadership aide told Business Insider that it was clear that McConnell was trying to ensure moderates were on board from the start.
"I think there is a very credible case to be made that this bill was center right to begin with and is still a center right bill," the former aide said.
Despite this, many moderate members are still cold on the bill due to the fact that it'll cut $772 billion cut out of the Medicaid budget through 2026.
This was identified as the biggest issue by a large number of moderates after the release of the first version of the BCRA and remains the largest complaint with the newest version.
There are some kickbacks for individual members. For instance, there are provisions in the bill that would shift a bit more of the funding to Alaska to please Sen. Lisa Murkowski. And there are some adjustments to how Medicaid funding is allotted in a public health crisis to shore up Marco Rubio's vote after he expressed some concerns.
Whether or not those will be enough to win over the needed votes remains to be seen. Since the bill is going through the budget reconciliation process, McConnell only needs to get a simple majority to pass the bill. Given the make-up of the Senate and the total opposition by Democrats, this means it'll take only 3 GOP defectors for the BCRA to fail.
Sen. Susan Collins of Maine immediately jumped out against the bill, saying that it did not address her concerns and she would vote against a key procedural vote, called a motion to proceed.
Other moderates like Rob Portman of Ohio, Dean Heller of Nevada, Shelley Moore Capito of West Virginia, and Alaska's Murkowski would not commit either way on a motion to proceed.
A Portman aide told Business Insider on Thursday that the senator "will review the text of the new bill and CBO analysis before making any decisions on this new version."
The best tactic in McConnell's arsenal may simply be to pressure the remaining hold outs on this side. Perhaps the best summation of the McConnell strategy with this side comes from a GOP aide who told Axios' Caitlin Owns a few weeks ago simply: "Moderates always cave."
Given the relative starting point of the bill compared to the House version, conservatives immediately took issue with the BCRA.
Sen. Ted Cruz of Texas, Rand Paul of Kentucky, Mike Lee of Utah, and Ron Johnson of Wisconsin immediately came out against the bill because it kept intact too much of Obamacare's regulatory structure and taxes.
This necessitated a concession to this group by McConnell, which came in the form of a consumer freedom amendment from Cruz. Under the new BCRA, insurers can offer plans that do not comply with two major Obamacare regulations, which experts worry could undermine protections for people with preexisting conditions.
Due to some differences between the plan presented by Cruz and Lee and the final product on rolling back the regulations (along with the preservation of the Obamacare taxes), the right wing of the party still hasn't been won over. Paul said he will not vote for the procedural vote to bring the bill to the floor. Cruz and Lee have not committed either way
"We do not like it," a Lee aide said of including of the Obamacare taxes. "There is a lot about the bill we do not like."
Still not enough
Even after tweaking the bill and trying to goose individual members, McConnell is still facing a simple math problem.
With Paul and Collins firmly against the motion to proceed, McConnell can only lose a single vote to even bring the BCRA to the floor for debate. Senators don't like to be the one person that killed a bill, but as of now even bringing the bill to the floor is not a slam dunk.
According to a Republican strategist familiar with leadership, however, the thin margin does not mean McConnell should be counted out.
"Nobody knows the Senate Republican conference better than McConnell, whose unique understanding of what each member wants is unparalleled in recent history," the strategist told Business Insider.
McConnell's track record and the funding available to him to shore up the support of members should be enough to get the bill across the finish line, said Rick Weissenstein at Cowen Washington Research Group,
"We continue to believe the Senate will narrowly pass a bill before the August break based on McConnell's prowess at cutting deals and the additional $230 billion in funds available to make changes to the bill to win over recalcitrant members," he said.
A planned vote on the Senate healthcare bill has been delayed at least a week by Majority Leader Mitch McConnell after Sen. John McCain underwent surgery Saturday and told leaders he would remain in Arizona for the week to recuperate.
Two GOP lawmakers — Sens. Rand Paul and Susan Collins — have already publicly said they would not support the bill, named the Better Care Reconciliation Act (BCRA).
Paul and Collins' opposition combined with McCain's absence leaves McConnell short of the 50 votes needed to pass the bill.
With experts saying McCain's recovery time could stretch longer than one week, it's unclear when the BCRA will make it to the Senate floor — if at all.
Whether or not the delay will be a good or bad thing for the bill is debatable.
On the one hand, it gives opponents of the BCRA more time to pressure moderate senators over the bill's Medicaid cuts and projected coverage losses. Given the razor's edge the bill sits on, if a flood of negative polls or analysis over the next week sways even a single undecided senator, the bill could be derailed.
Sen. Susan Collins, a moderate, told ABC's This Week on Sunday that there are "eight to 10" Republican members with "deep concerns."
No one wants to be the deciding vote to kill a bill, but if one member does publicly become the deciding vote, others may follow.
Also complicating factors is Sen. Ron Johnson. Johnson originally came out against the BCRA for not being conservative enough, but said after the release of the updated bill that he was on board. Over the weekend, however, Johnson told the Green Bay Press-Gazette in his home state of Wisconsin that he was back to undecided on the bill due to reports that McConnell told moderate members that the deep cuts to Medicaid that are in the bill would never go into effect.
Another big issue for lawmakers on the fence is the release of the Congressional Budget Office's score for the updated BCRA. The original score, which showed that 22 million more Americans would be without health insurance in 2026 under the BCRA compared to the current system, was a key point of contention for centrist Republicans who opposed the first iteration of the healthcare bill.
The new score was originally set to be released on Monday, but, given the delay for the vote, it will also be pushed back. It's unclear when it will be released now, but reports suggest it could be as late as next week.
On the other hand, no senator has come out as the key third "no" vote that would doom the bill and, according to Axios' Jonathan Swan, The White House and McConnell view each day without another public defector as a "victory."
It also gives more time for McConnell, who is known as an adept dealmaker, to work with individual senators to address their issues or create amendments to placate their particular concerns. Already, the bill includes multiple carve outs for certain states or issues particular senators care about.