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June 13, 2017

Dead or alive? What 10 key senators' comments mean for the ACA's future

Daily Briefing

    By Josh Zeitlin, Editor

    The Senate's effort to repeal major parts of the Affordable Care Act (ACA) has long seemed an uphill battle: GOP leaders can afford to lose only two votes from members of their party, and many Republican senators have raised major concerns.

    But over the last week, the momentum has seemed to shift: Several Republican senators who ACA backers hope will vote against the Senate's potential, yet-to-be-released health care bill now sound far more open to voting yes.

    A 'very optimistic' swing vote (and doctor)

    Take Sen. Bill Cassidy of Louisiana, a physician who said in May that any bill had to pass the "Jimmy Kimmel test" and ensure that "if somebody has a crisis, they have the coverage." Cassidy panned the House-passed American Health Care Act (AHCA) and said he wants a bill that would expand coverage.

    According to the latest reports on the Senate's health care talks, the chamber's working bill wouldn't seem to meet that standard. For instance, like the House version, it reportedly would allow states to waive the ACA's essential health benefits requirements, which would undermine protections for patients with pre-existing conditions. 

    Yet last week, Cassidy sounded likely to support a final Senate bill. He said he was "very encouraged" by the chamber's talks after a presentation by Senate Majority Leader Mitch McConnell of Kentucky. "Of course, it's not everything I want," Cassidy added, "but that's life." He told the New York Times the odds of Senate passage were "better than 50-50."

    Cassidy isn't alone

    Several other Republican senators perceived to be swing votes have changed their tone in recent weeks, too.

    • Sen. Dean Heller of Nevada in May said the House-passed AHCA "does not do enough to address Nevada's Medicaid population or protect Nevadans with pre-existing conditions." Last week, he told reporters he supports a seven-year phase-out of the ACA's Medicaid expansion, and that negotiations were "moving in the right direction."

    • Sens. Rob Portman of Ohio and Shelley Moore Capito of West Virginia in March wrote in a letter that the draft of the AHCA at the time "does not provide stability and certainty for individuals and families in Medicaid expansion programs or the necessary flexibility for states." Last week, both expressed support for a seven-year phase-out of the ACA's Medicaid expansion 

    • Sen. Cory Gardner of Colorado also signed that letter, but as a member of the GOP leadership team he has signaled his support of the Senate's efforts. Last week, he said he expects the Senate to advance health care by August and said President Trump "knows [a health care bill] needs to get done."

    • Sen. Lisa Murkowski of Alaska also signed that letter, and in February said she would vote against ending Medicaid expansion if her state wanted to keep it. But last week, she declined to reiterate that stance, saying only, "We're still working through all the specifics on Medicaid." Murkowski did add that as of last week, there was still "a wide divergence of views on a great deal of what is under discussion, whether it is how we deal with Medicaid expansion, how we deal with pre-existing conditions, how we deal with tax credits."

    • Sen. Susan Collins of Maine, who has panned the House-passed AHCA, last week expressed concern about cuts to coverage—but expressed optimism about the Senate's efforts. In one interview, Collins said she could not support a bill, like the House-passed AHCA, "that results in 23 million people losing coverage." But in another interview, she expressed hope about the Senate talks, which are aiming to cover more Americans than the House bill. "From the outline of the Senate bill that I've seen—and there are a lot of specifics that I'm not yet aware of—it is a far more thoughtful and appropriate bill than the House version, but there are a lot of unanswered questions yet," she said.

    A possible conservative 'revolt'—and major uncertainty

    While those largely moderate Republican senators have expressed increased optimism about the chamber's health care efforts, several others across the past week or two have expressed significant pessimism.

    Sen. Richard Burr of North Carolina said on June 1 that it's "unlikely we will get a health care bill." And Sen. Lindsey Graham of South Carolina last week said he didn't think a health care bill could pass in 2017 because of disagreements over Medicaid expansion.

    Graham also raised another concern—that the conservative Sen. Rand Paul of Kentucky was "irrevocably" against the bill because of his opposition to its premium tax credits. A Paul spokesperson pushed back, saying the senator "remains optimistic the bill can be improved in the days ahead and is keeping an open mind." Still, Politico on Friday reported that Republicans are "increasingly pessimistic" that Paul and fellow conservative Sen. Mike Lee of Utah would support the Senate's eventual bill.

    One GOP health care lobbyist was particularly colorful in expressing his pessimism last week to Vox's Dylan Scott. The lobbyist said it was certain that a Senate health care bill would fail, but that the chamber would likely hold a vote anyway, adding, "They have to be able to show the electorate a body, to say that they tried and failed."

    Still, other Republican senators have expressed confidence—and stressed patience. Sen. John Cornyn of Texas said of the Senate's health care effort, "It's like having a baby. It's not here yet, but it's coming," adding "I'm optimistic."

    Dead or alive: Which is it?

    As of right now, it appears that Senate Republicans' health care efforts aren't certain to succeed, but they aren't dead either.

    Axios reported that a draft Senate bill "had been expected to be finished" Monday night, but that "timing has slipped"—and that in any event, Republicans don't plan to publicly release drafts, as one aide said they are "still in discussions about what will be in the final product."

    And therein lies the difficulty in assessing the health of the Senate health bill: There isn't a bill yet. Clearly, most or all GOP senators want to get to yes, and their comments this week are indicative of that. It's also difficult to determine which senators plan to vote yes in the end and are just trying to use leverage to change the bill as much as they can, and which senators are more seriously contemplating voting no.  

    Much remains uncertain, but don't forget that the House's version of AHCA appeared dead several times before it passed—as did the ACA itself. GOP senators' comments from the past week suggest that Republicans' health care efforts are not dead yet—and could well ultimately result in a bill's passage.

    5 things everyone should know about MACRA (which wouldn't change under the AHCA)

    MACRA is the biggest overhaul to Medicare physician payment in a decade—and because it passed Congress with bipartisan support, it's almost certainly here to stay.

    That means you need to understand how MACRA ups the ante on pay for performance, doubles down on population health, and more. Check out our infographic to learn the no-regrets strategies you can implement now to prepare.

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