Senate GOP leaders work to round up votes for modest health-care overhaul

WASHINGTON – Senate Republican leaders continued working Thursday to round up votes for a modest overhaul of the Affordable Care Act, as lawmakers pressed ahead with a series of votes that underscored the GOP's deep divide on how to fix the nation's health-care system.

On Wednesday the Senate rejected a proposal that would have repealed major parts of the ACA outright, with seven Republicans joining the chamber's Democrats in opposition.

But GOP leaders said they were cautiously optimistic that later this week they could pass a "skinny repeal" that would abolish the individual and employer insurance mandates and perhaps just one tax in an attempt to sustain their seven-year quest to unwind President Barack Obama's health-care law. Even if they succeed – and start negotiations with the House – they will face significant obstacles in accomplishing anything more substantial.

Speaking on the Senate floor Thursday, Senate Majority Leader Mitch McConnell (R., Ky.) emphasized that the series of votes this week would not reverse the law even if they culminate in passage of a bill. The votes are expected to be held through the night and into Friday morning.

"One phase of that process will end when the Senate concludes voting this week, but it will not signal the end of our work. Not yet," McConnell said.

While McConnell predicted there would be an all-night marathon of votes, Democrats have decided to save their political ammunition until Republicans reveal the substance of the skinny repeal that they have been crafting.

Senate Minority Leader Charles Schumer (D., N.Y.) said in a Senate floor speech that Democrats would offer no more amendments until that point, so Republicans could not claim that their final bill was the product of extensive Senate deliberations.

Schumer said that if the skinny repeal plan passes, the Senate should then be prepared for "numerous" Democratic amendments, which could potentially force Republicans into politically tough votes.

Top Republicans such as Sen. John Thune of South Dakota, No. 3 in the chamber's GOP hierarchy, said that although leaders have not yet found "the sweet spot" between conservatives and centrists, they have picked up support for a more modest plan because it does not include deep cuts to Medicaid. Some Republican senators were simply open to any legislation that could keep alive the roller-coaster push for an overhaul.

"We're edging closer and closer" to getting 50 votes for a bare-bones plan, Thune said. He said leaders were betting that some Republicans who defected on votes this week would feel more pressure to support any bill that emerged from negotiations with the House to face a final vote in the Senate.

"Voting on something at the end of the process when it's the only train leaving the station . . . I think that's a different vote for a lot of people," he said.

To muster enough votes for a narrow bill, GOP leaders suggested that even some proposals that have died in the Senate could come up again once they enter negotiations with the House. And some members have begun to try to add a few additional provisions to the skinny bill, using their leverage to try to strengthen their negotiating position in conference.

Sen. Rob Portman (R., Ohio) is pushing for the inclusion of $45 billion to treat opioid addiction, Republicans familiar with the talks said Thursday. It was unclear whether the funds would be included, given the bill's budget constraints. Aides to Portman and McConnell did not immediately comment.

Portman and Sen. Shelley Moore Capito (R., W.Va.) successfully lobbied leadership to include the money in the more sweeping repeal-and-replace bill that the Senate voted down earlier this week. But it was unclear whether they would prevail once again.

Sen. Lindsey Graham (R., S.C.) said he was willing to go along with the leadership's latest legislative approach to extend the negotiations in a House-Senate conference committee – but only if he received assurances that his ideas could be resurrected in that setting.

"I won't vote for the skinny bill unless Graham-Cassidy is conference-able," said Graham, referring to an alternate health bill he has offered with Sen. Bill Cassidy (R., La.) that has gained little traction.

More than half a dozen centrists from states that expanded Medicaid under the Affordable Care Act objected to the original Senate draft that GOP leaders crafted last month. It would have cut the program for low-income Americans by $772 billion over 10 years and curtailed its long-term growth rate.

President Trump exhorted Republicans on Twitter on Wednesday morning to fall in line and back some sort of proposal to scale back the law known as Obamacare.

While McConnell has led the negotiations over a health-care plan for weeks, Trump has sought to drum up support by publicly pressing wavering Republicans.

In an interview with the Alaska Dispatch News, Sen. Dan Sullivan (R., Alaska) said that Interior Secretary Ryan Zinke called him and Sen. Lisa Murkowksi (R., Alaska) separately on Wednesday to warn them that the administration may change its position on several issues, given Murkowski's vote against proceeding with health-care legislation this week.

Since Trump took office, Interior has indicated it is open to constructing a road through the Izembek National Wildlife Refuge and drilling in the Arctic National Wildlife Refuge while expanding energy exploration elsewhere in the state. But now these policy shifts may be in jeopardy.

"I tried to push back on behalf of all Alaskans," Sullivan said. "We're facing some difficult times, and there's a lot of enthusiasm for the policies that Secretary Zinke and the president have been talking about with regard to our economy. But the message was pretty clear."

Interior officials did not immediately respond to a request for comment.

Even if Republicans agree on a minimalist plan to alter the ACA, uniting with their House colleagues to enact a bill would be far more challenging. On Wednesday – even before the skinny repeal came up for a vote – some House conservatives were calling it untenable.

Rep. Mark Meadows (R., N.C.), chairman of the House Freedom Caucus and a key player in negotiating the House-passed bill, told reporters recently that a skinny repeal would be "dead on arrival" in the House and that a conference committee would have to be convened to work out a compromise.

Still, House Speaker Paul Ryan (R., Wis.) said Thursday that House leaders are "considering" extending their session so they can be prepared to act on whatever the Senate approves this week.

"The question is, what is the Senate going to do?" Ryan said. "We don't know what the Senate is going to do, so therefore we will reserve judgment as to what our response is."

McConnell overcame serious opposition from his rank-and-file members to begin debate on health care – a prospect that seemed dim just last week. Trump has taken to Twitter and made public statements challenging Senate Republicans to support an overhaul or take ownership of the ACA's failure.

But in two votes within 24 hours of each other, lawmakers rejected differing approaches to rewriting the landmark 2010 law. The open voting process – which is likely to drag on for the rest of the week – has laid bare the fact that Senate Republicans have not been able to find a comprehensive replacement for the law they have relentlessly lambasted.

Republicans on Wednesday lacked answers for how or even whether they can break their gridlock by simply extending their endeavor, but they appeared determined to press ahead.

"I think it's a good idea to start with what we agree on and see how big we can get the bill from there," said Kentucky Sen. Rand Paul, who has pushed for a repeal of the law and has repeatedly clashed with GOP leaders.

Asked later whether he worried about the impact of repealing the mandate that individuals buy insurance or pay a tax penalty, Paul replied, "The insurance market's a disaster now."

"No matter what you do, unless you're willing to repeal all the regulations, it'll be a disaster in 2018," he added. "It's not the fault of Republicans. It's the fault of Obamacare."

GOP leaders have little room to navigate when it comes to crafting a bill, as just three defections within their ranks would deprive them of the 50 votes they need to pass legislation with the assistance of Vice President Pence, who can break a tie.

And in each of the two most important votes the Senate has cast since taking up the bill, at least 13 percent of Republicans defected to join Democrats in opposition. .

Senate Majority Whip John Cornyn, Texas, said proposals offered by Portman and Ted Cruz (R., Texas) that were rejected Tuesday as part of a broader rewrite measure could resurface.

Portman's measure calls for adding $100 billion in federal funding to help consumers with out-of-pocket medical costs and allowing states to provide cost-sharing assistance to low-income people who transition from Medicaid to private insurance with a federal tax credit. Cruz's amendment would let insurers offer health plans on the ACA market that do not provide the full benefits required under the law, as long as they offer at least one option that does.

A total of 57 senators, including nine Republicans, voted against the measure that included both of those provisions. But Cornyn said that passing a skinny repeal would buy time for the Congressional Budget Office to score those two plans, which may be revisited in a conference committee.

With the idea of a scaled-back bill emerging as the most likely outcome of this week's votes, the proposal now faces increased scrutiny.

Senate Democrats announced late Wednesday afternoon that a preliminary CBO estimate found that 16 million people would lose coverage and that premiums would rise 20 percent if Republicans enacted a handful of the policies floated for the pared-down repeal bill. The analysis was based on the assumption that the GOP wants to repeal the individual and employer mandates, end a 2.3 percent tax on medical device manufacturers, ban funding for Planned Parenthood and repeal funds for preventive health care.

In a sign of how the prospect of a spike in the uninsured rate continues to worry governors, a bipartisan group of 10 of them – including Republicans Brian Sandoval of Nevada and John Kasich of Ohio – urged Senate leaders late Wednesday to work together with governors in developing a new plan and to reject a skinny repeal, which they said "is expected to accelerate health plans leaving the individual market, increase premiums, and result in fewer Americans having access to insurance."

Senate Republicans hope that once their members are faced with enacting an imperfect measure, or not accomplishing one of their chief legislative goals, they will decide that some progress is better than none.

The Senate also voted down a pair of attempts by Democrats to end debate by forcing two Senate committees to review and debate the legislation, and an amendment from Sen. Dean Heller (R., Nev.) affirming support for Medicaid and asking for the Senate to review the program further. Democrats grew frustrated by the spectacle Wednesday evening and threatened to stop offering amendments until GOP leaders released details of the narrow repeal measure they plan to offer.

Meanwhile, the ongoing uncertainty on Capitol Hill sent jitters through the insurance industry.

Joseph Swedish, the chief executive of Anthem – the nation's second-largest health insurer – said on a conference call to review second-quarter earnings that the company is reassessing its participation in ACA marketplaces for next year. Anthem has decided to largely withdraw from the markets in three of the 14 states it participates in, and he said it may stop participating elsewhere unless the markets seem stable.

The Blue Cross Blue Shield Association warned that even the skinny repeal Republicans now envision could undermine the individual insurance market because it would eliminate the individual mandate. The measure, which remains subject to negotiation, also would probably eliminate the ACA's requirement that employers with 50 workers or more provide health coverage, and a medical device tax that generates $19.6 billion in federal revenue over a decade.

"If there is no longer a requirement for everyone to purchase coverage, it is critical that any legislation include strong incentives for people to obtain health insurance and keep it year-round," the Blue Cross Blue Shield Association said in a statement.

And America's Health Insurance Plans, a major insurance trade association, weighed in with a letter Thursday saying it opposes "targeted proposals that would eliminate key elements of current law without new stabilizing solutions."

Several Republicans appeared wary Wednesday of moving too quickly to undo the health-care law without a replacement in hand. That proposal was defeated on a vote of 55 to 45, with seven Republican senators – including John McCain of Arizona and Lamar Alexander of Tennessee, who chairs one of the key committees that would normally craft a health-care bill – opposing it.

Alexander said after the vote that although he supported an outright repeal in 2015, his constituents could not tolerate that kind of uncertainty now.

"I don't think most Tennesseans would like the idea of our saying to them, 'We're going to cancel insurance for 22 million Americans and then trust Congress to replace it in two years,' " he said. "I think most pilots, when they take off, like to know where they're going to land."

Dino Grandoni, Amy Goldstein, David Weigel and Mike DeBonis contributed to this report.