Divide opens within GOP on health bill

It appeals to conservatives, but party’s moderates wary

Sen. Lisa Murkowski, R-Alaska, expressed concerns Friday about the Senate’s health care bill, saying she remains committed “to ensuring that all Alaskans have access to affordable, quality health care.”
Sen. Lisa Murkowski, R-Alaska, expressed concerns Friday about the Senate’s health care bill, saying she remains committed “to ensuring that all Alaskans have access to affordable, quality health care.”

Concerns from moderate GOP senators that their party's health care bill cuts too deeply into Medicaid and would leave the nation's most vulnerable people with no health insurance are shaping up to be a significant obstacle to the measure's passage.

Their concerns have laid bare an ideological fault line within the GOP. Though Senate conservatives were the first to threaten to torpedo the bill, contending that it is too generous, the potential loss of support from nearly half a dozen moderate lawmakers is growing as just as big a problem.

With the bill likely to get no support from Democrats, Senate Majority Leader Mitch McConnell, R-Ky., can afford to lose the support of only two Republicans and still get the bill passed. He hopes to put the measure to a vote this week.

On Saturday afternoon, President Donald Trump vented on Twitter about Republicans who are not supporting the Senate bill.

[DOCUMENT: Read text of full bill]

"I cannot imagine that these very fine Republican Senators would allow the American people to suffer a broken ObamaCare any longer!" Trump tweeted.

The bill's odds worsened Friday when Sen. Dean Heller, R-Nev., who is up for re-election next year, said he could not support it in its current form. Heller specifically cited its cuts to Medicaid, not just by ending its expansion in Nevada and 30 other states but by restricting government spending for the program starting in 2025.

Though three of the other four wavering GOP centrists also represent Medicaid-expansion states, not all were as explicit as Heller in their reactions after the Better Care Reconciliation Act was unveiled late last week. Republican Sens. Shelley Moore Capito of West Virginia and Lisa Murkowski of Alaska said they would evaluate it with an eye toward its effect on low-income residents.

"It needs to be done right," Murkowski said in a tweet. "I remain committed to ensuring that all Alaskans have access to affordable, quality health care."

[INTERACTIVE: Compare new health care bill with Affordable Care Act]

Chief lieutenants in the political network of the billionaire industrialist Koch brothers, on the other hand, criticized the Senate bill Saturday as not conservative enough.

Tim Phillips, who leads Americans for Prosperity, the Koch network's political arm, called the Senate's plans for Medicaid "a slight nip and tuck" of President Barack Obama's health care law, a modest change that he described as "immoral."

"This Senate bill needs to get better," Phillips said. "It has to get better."

Several conservative senators have voiced opposition to the bill because they feel it does not go far enough in dismantling the Affordable Care Act.

Koch network spokesman James Davis said the organization would continue to push for changes to the Senate health care bill over the coming week.

At least two of the current GOP opponents, Sens. Mike Lee of Utah and Ted Cruz of Texas, were among 18 elected officials scheduled to attend this weekend's Koch retreat in Colorado Springs. Two more party undecideds were also on the guest list: Sens. Jeff Flake of Arizona and Ben Sasse of Nebraska.

Budget projections

Congressional budget analysts plan to issue their projections as early as Monday on the legislation's effect on the federal deficit and the number of Americans whose insurance coverage it will impact.

Under the Senate GOP version, Medicaid's transformation would begin in 2021. The Medicaid expansion, which has provided insurance coverage to roughly 11 million people, would be phased out. What is now an open-ended program, with federal funding available for a specific share of whatever each state spends, would be converted to per capita payments or block grants.

Then, four years later, the federal government would apply an inflation factor to spending increases that would be equal to the urban consumer price index rather than the higher medical inflation rate used in the House bill.

Medicaid pays for most of the 1.4 million elderly people in nursing homes. It covers 20 percent of all Americans and 40 percent of low-income adults.

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Under federal law, state Medicaid programs are required to cover nursing home care. But state officials decide how much to pay the facilities, and states under budgetary pressure could cut the amount they are willing to pay or restrict eligibility for coverage.

"The states are going to make it harder to qualify medically for needing nursing home care," predicted Toby Edelman, a senior policy attorney at the Center for Medicare Advocacy. People would "have to be more disabled before they qualify for Medicaid assistance."

A combination of longer life spans and rising health care costs has left an estimated 64 percent of Americans in nursing homes dependent on Medicaid. In Alaska, Mississippi and West Virginia, Medicaid was the primary payer for three-quarters or more of nursing home residents in 2015, according to the Kaiser Family Foundation.

With more than 70 million people enrolled in Medicaid at an annual cost of more than $500 billion, the program certainly faces long-term financial challenges. Federal Medicaid spending is on track to grow 6 percent a year on average, rising to $650 billion in 2027 from $389 billion this year, according to the Congressional Budget Office.

While most Medicaid enrollees are children, pregnant women and nonelderly adults, long-term services such as nursing home care account for 42 percent of all Medicaid spending even though only 6 percent of Medicaid enrollees use those services.

"Moms and kids aren't where the money is," said Damon Terzaghi, a senior director at the National Association of States United for Aging and Disabilities, a group representing state agencies that manage programs for these populations or advocate on their behalf. "If you're going to cut that much money out, it's going to be coming from older people and people with disabilities."

Insurers worried

Meanwhile, insurers are fretting about the Senate legislation because it would repeal the individual mandate but -- unlike the House bill -- not provide an incentive for people to retain coverage.

The mandate requires most people to have insurance coverage or pay a penalty.

Abolishing the health care law's mandate with no penalty for coverage lapses would destabilize the individual insurance market by leading healthy people to drop their coverage, the companies say, leaving insurance companies with sicker, more costly plan members in their enrollee risk pool.

As a result, premiums would increase as much as 20 percent, according to government estimates, making coverage unaffordable for many people. And people with medical problems could game the system by enrolling only when they get sick.

"Particularly, if there's something like, you know, you have to have knee surgery in April. And then sign up for coverage, get the surgery and then drop it," said Katie Allen, executive director of the Council for Affordable Health Coverage. To avoid that scenario, the House Republican legislation imposes a 30 percent surcharge on people who let their individual insurance lapse.

But Senate Republicans didn't include the surcharge in their legislation because the provision conflicts with the Senate's "Byrd Rule," a parliamentary rule that governs what can be included in a budget reconciliation bill. The health bill is being presented as a budget reconciliation bill to avoid the prospect of a filibuster by Democrats, which would require 60 votes to pass it instead of 51.

Andy Slavitt, former acting administrator of the federal Centers for Medicare and Medicaid Services in the Obama administration, said Republicans "don't have a good answer."

Not so, said Tara O'Neill Hayes, deputy director of health care policy at the conservative American Action Forum.

In a blog post, Hayes outlines several options that Republican Senate aides could consider in place of the 30 percent surcharge.

Those options include waiting periods to access insurance benefits for people who have let their coverage lapse, a tactic insurers used before the Affordable Care Act became law.

Information for this article was contributed by Jordan Rau and Jennifer Steinhauer of The New York Times; by Tony Pugh of Tribune News Service; by Steve Peoples of The Associated Press; and by Juliet Eilperin and Amy Goldstein of The Washington Post.

A Section on 06/25/2017


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Despite wavering support from several GOP senators, Senate Majority Leader Mitch McConnell still hopes to put the measure to a vote this week.

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