It’s been a busy few weeks in the world of health care. Advocates breathed a quick sigh of relief last week when four GOP senators – Sens. Collins (ME), Paul (KY), Moran (KS), and Lee (UT) – said they would vote against beginning debate on a bill spearheaded by Majority Leader Mitch McConnell to repeal the Affordable Care Act and replace it with legislation that would leave 22 million more Americans without health insurance. After Sens. Collins (ME), Capito (WV), Murkowski (AK), and other senators also said on July 18 they would vote against moving forward on a bill to repeal the ACA without a replacement plan in place, which the nonpartisan Congressional Budget Office said would result 32 million more people uninsured by 2026, the GOP’s efforts to kill former-President Obama’s signature legislation seemed for a moment to be dead. Prodded on by President Trump, however, Senate leadership continue to try to revive their repeal and replace bill, and a vote on one of these bills could take place in the Senate as early as Tuesday, July 25. Senate leaders are using a special process known as reconciliation where only 51 votes are needed to move a bill, but it is unclear if they can meet this threshold or even which bill they would be taking up.

The CBO analysis of the Senate GOP’s latest edition of their repeal and replace bill – which also includes $756 billion in cuts to Medicaid – did not include an amendment proposed by Sen. Ted Cruz (R-TX) that would allow insurance companies to offer plans with skimpy coverage that aren’t allowed under the ACA, as long as they also offer at least one plan that meets ACA coverage requirements. Advocates fear this amendment would wipe away protections for people with pre-existing conditions and cause premiums to spike for sick people.

In an effort to win over some of the ‘no’ votes of senators from states that expanded Medicaid under the ACA, Senate leaders reportedly offered to add $200 billion to the bill to supplement private coverage for those who gained Medicaid coverage under the expansion but would lose it under the Senate bill. But the Center on Budget and Policy Priorities showed that $200 billion is only 17 percent of the bill’s $1.2 trillion in cuts: $756 billion from Medicaid and $427 billion from subsidies to help low- and moderate-income people buy coverage in the individual market. They also showed how a repeal bill without a replacement plan would be even more harmful.

Another hurdle to passage came on Friday, July 21 when the Senate parliamentarian ruled that several parts of the Senate ‘repeal and replace’ bill would violate the chamber’s so-called Byrd rule. Named after former Senator Robert Byrd (D-WV), the rule states that legislation moved under the reconciliation process can only include changes to laws that directly affect the federal budget and can be scored by the Congressional Budget Office. Among the key provisions the parliamentarian ruled against include provisions that would: impose a six-month “lockout” period from purchasing insurance for people who had gone without insurance for more than 63 days, defund Planned Parenthood, and fund the cost-sharing reduction subsidies insurers rely on to keep premiums and deductibles low (since this provision replicates current law), as well as certain state-specific provisions. These provisions would therefore have to be stripped from the bill, unless there were 60 votes to overturn the ruling of the parliamentarian, exceedingly unlikely since that would require votes from Democratic senators. The Senate Budget Committee Minority Staff released a document with an outline of all of the provisions that meet and don’t meet the Byrd rule according to the parliamentarian, as well as those still under review. The parliamentarian did not rule on the Cruz amendment mentioned above, but did rule that provisions allowing states to impose work requirements on certain Medicaid enrollees and one that would repeal cost-sharing subsidies beginning in 2020 would be allowed under the Byrd rule. A provision to allow states to receive Medicaid funding in the form of a block grant is still under review. According to the Atlantic, Vice President Mike Pence, as the presiding officer of the Senate, could choose to overrule the parliamentarian, although this hasn’t been attempted for more than 40 years.

The Trump Administration announced on July 19 that it would make July payments to insurers for helping lower-income people afford some out-of-pocket costs. It did not say anything about the future of these payments, known as cost-sharing reductions. Many believe that a failure by the administration to continue these payments would lead to more insurers pulling out of the exchanges, increased premiums, and more instability in the marketplaces.

Advocates continued calls to their senators throughout the weekend to reiterate their hopes that senators reject efforts to repeal the ACA and end Medicaid as we know it, and instead work on a bipartisan approach to strengthening insurance markets, affordability and the health care system overall.

For more information, see the Protect Our Care Coalition website, these blogs, and the June 12 Human Needs Report.

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