Déjà vu All Over Again

On Thursday, Senate Majority Leader Mitch McConnell released a revised version of the BCRA, the healthcare reform bill that’s really a bill focused on cutting both taxes for the rich and benefits for the poor. The entire process seems to at least mirror the previous bill’s, if not just cut and paste it. The CBO was set to release its score of the revised bill early this week, but with McCain being absent from the Senate due to surgery, that score was delayed, as well as the vote itself. Despite (or perhaps because of) the bill’s similarity to the previous version, enough Republican Senators have declared their intentions to vote No on a motion to proceed with the bill, resulting in yet another effectively failed attempt at an ACA repeal.

On the whole, this version wasn’t particularly different than the previous Senate bill. It still enacted savage cuts to Medicaid, loosened restrictions and regulations on the kind of insurance offered, allowed insurance companies to charge different demographics (i.e. older people) more for their insurance, and so on. The latest revision kept two taxes from the ACA that were previously cut. It allocated $45 billion dollars over 10 years to fight the opioid crisis instead of two billion, an amount which is still not adequate to deal with the problem. It expanded the allowed usage of Health Savings Accounts (or HSAs), but those are only used by people who can afford to maintain and add to them, making this provision useless for those with lower incomes. The bill also allocated $70 billion to help stabilize higher risk pools, but the implementation involves matching by the states, so in total the stabilization is $132 billion. We won’t know whether this fund would be sufficient to keep the markets stable until official estimates come out (assuming the bill will still be scored).

A late addition to this version of the bill was an amendment by Senator Ted Cruz (R-TX) that would allow insurance providers to provide plans that did not conform to ACA regulations, as long as they also offered plans that did. The CEOs of AHIP and Blue Cross/Blue Shield, the largest medical insurers in the US, released a letter calling the amendment’s plan “unworkable.” As this amendment was offered late, it was not included in the CBO submission. John Thune of South Dakota, the Republican Conference Chair, suggested allowing the HHS to score the amendment under the assumption that Secretary Price’s department would be much more favorable to the bill than the nonpartisan CBO. It is not clear whether this would comply with Senate rules.

Last time around, several Republican Senators declared they would not vote for the previous version of the BCRA. Some are seen as more moderate, or represent states whose greater populations of elderly or opioid-afflicted citizens are especially vulnerable to the BCRA’s cuts. In order to pass any version of this bill, McConnell needs them to flip and vote to approve it; he can only have two senators vote no and still succeed. Two senators, Rand Paul of Kentucky and Susan Collins of Maine, declared early on they would not vote for the revised bill, although for drastically different reasons. Paul believed that the new bill still hewed too close to the Affordable Care Act, and Collins remains against any drastic cuts to Medicaid. This meant McConnell could not spare any more No votes throughout his caucus. Senator Heller of Nevada has not yet commented on the new bill, although the Governor of his state, Brian Sandoval, has declared his opposition. Senator Capito of West Virginia declared she was waiting for the CBO, as did Senator Portman (R-OH). In what almost seems like a deliberate echo, the other potential no votes were also waiting for the CBO score.

Just like last time, McConnell planned for the vote later this week, extremely soon after the CBO score. Once again there would be no time for hearings, amendments, or the other processes that the Senate normally follows for legislation. The plan was and is still as little outside input as possible. However, Senator McCain of Arizona had surgery on Saturday, and on advice from his doctors will remain in Arizona for the week. McConnell announced he would “defer consideration” of the bill, effectively delaying it. With the August recess postponed, the Senate still has some time for health care reform (they also have to deal with the debt ceiling and a budget), but every delay increases the chance that this extremely unpopular bill will once again succumb to public pressure, no matter what minor revisions are made.

Late Monday night, Senators Moran of Kansas and Mike Lee of Utah announced that they too would not vote for the bill. This means the current bill is effectively dead. In the end, it was so unpopular that 41 of the 52 GOP senators were unwilling to commit to the bill at all. Mike Lee felt that even with the Cruz amendment, the bill did not move far enough in his preferred direction for health care policy. Moran’s objection, however is a little more intricate. Throughout the week, it was discovered that McConnell had been telling more moderate Republican senators that the Medicaid cuts couldn’t possibly go through, as future congresses and presidents wouldn’t allow such drastic reductions in services. This cynical double speak (echoing what Republicans said about the sequester, which did pass and is still in effect) angered Senator Johnson of Wisconsin, who feels that the Medicaid expansion was damaging to the healthcare system, and that the new healthcare bill needed those cutbacks. He withdrew support of the bill, which led Senator Moran to declare he would not vote for it.

However, while this bill is effectively dead (again), McConnell’s efforts to affect the health care system are not over. He wants those tax cuts, and will work extremely hard to get them. He has already declared his next attempt: Repeal now, replace later. America, and its Senate Republicans, seem doomed to an endless cycle of ACA repeal efforts until either a version arrives which garners near-universal support from a fractured GOP caucus or McConnell and the other Republican leaders admit defeat and move on.