July 25, 2017

McCain is back. The Senate will vote today on health reform.

Daily Briefing

    Editor's note: This story will be updated as news continues to develop.

    After weeks of negotiations, Senate Republican leaders will hold a procedural vote Tuesday afternoon to begin debate on a health reform bill—though it remains whether there is enough support to even begin debate.

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    Senate Majority Leader Mitch McConnell (R-Ky.) in a speech on the Senate floor Monday night said, "Many of us have waited literally years for this moment to finally arrive and, at long last, it has." He added, "I will vote' yes' on the motion to proceed and I would urge all of our colleagues to do the same."

    Though Republicans appeared to gain renewed momentum Monday night with the announcement that Sen. John McCain (R-Ariz.), who last week was diagnosed with brain cancer, will return to Washington D.C. Tuesday to cast his vote, it remains unclear how many Republicans will vote in its favor.

    Senate Majority Whip John Cornyn (R-Texas) said GOP senators during Tuesday's Senate Republican lunch will "further discuss" the substance of their health reform plans, which likely will be shaped by amendments. A McConnell spokesperson Don Stewart said that "members are discussing timing" for the amendments.

    The bills that could (possibly) come to a vote

    Senate GOP leaders are reportedly considering moving forward with either:

    • A revised Better Care Reconciliation Act (BCRA), which would repeal and replace major parts of the Affordable Care Act (ACA), as well as restructure and reduce funding for Medicaid by turning it into a per capita allotment model. According to the Congressional Budget Office (CBO), the bill would leave 22 million more individuals uninsured while reducing premiums but significantly increasing deductibles for benchmark plans by 2026; or
    • A revived 2015 "repeal-and-delay" measure, which would immediately repeal major ACA provisions, including the law's coverage mandates, and in 2020 would eliminate funding for the law's Medicaid expansion and insurance premium subsidies, with the expectation that Congress would in the meantime pass an ACA replacement plan. CBO estimated that this bill would increase the United States' uninsured population by 32 million people and roughly double health plan premiums by 2026.

    According to The Hill, Senate GOP leaders also are considering offering a bill that is narrower in scope than the two other proposals in an effort to approve some measure and set up broader negotiations to reconcile the House and Senate bills. According to GOP senate aides, the narrower bill would likely repeal only the ACA's individual and employer mandates and medical device tax.

    However, all of these proposals could change further before Tuesday's vote is held. GOP aides reportedly are already revising the BCRA in light of guidance from the Senate's parliamentarian. And GOP senators also are considering a proposal by CMS administrator Seema Verma that would give states up to $200 billion in additional funds to subsidize the cost of private insurance for individuals who gained Medicaid coverage under the Affordable Care Act's expansion. A recent analysis by the Urban Institute, however, suggests that amount would provide sufficient funding for only a few years, after which affected individuals could be left to pay higher premiums. 

    Here's how the vote is expected to unfold

    After the Senate GOP's lunch, McConnell is expected to call a vote on a motion to proceed to the House-passed AHCA.

    If that vote succeeds—which remains uncertain—McConnell would then offer a substitute amendment that would swap out the House-passed bill for one of the Senate's proposals. According to Axios, sources have said the first amendment offered would likely be the revived repeal-and-delay bill, although that could still change. Sen. Rand Paul (R-Ky.) in a tweet Tuesday also confirmed that McConnell plans to take up the repeal-and-delay bill.

    If the repeal-and-delay amendment is indeed offered first, three scenarios could play out.

    If the vote succeeds, the clock would begin on 20 hours of debate. From there, lawmakers would move on to the "vote-a-rama," during which lawmakers would be able to offer amendments as well as points of order to strip out provisions that may conflict with the chamber's reconciliation rules. If the parliamentarian agrees that those provisions do not comply with Senate rules, they would require at least 60 votes to remain in the bill. Throughout the process, Senate GOP leaders would continue to negotiate provisions in an effort to secure votes from members who are on the fence and could offer a revised bill as a final substitute.

    If, on the other hand, the vote to swap the AHCA out for the repeal-and-delay bill fails, McConnell could instead offer to replace the House bill with the Senate's latest version of the BCRA. If that vote succeeds, lawmakers would then advance to debate and the amendment vote-a-rama as described above.

    If votes on both the repeal-and-delay bill and BCRA fail, senators could vote to amend the House-passed AHCA. Alternatively, The Hill reports McConnell could then offer the scaled down version of the Senate's repeal bill.  

    As Cornyn put it, "endless amendments" could be offered if the initial procedural vote passes. "Everybody will get a vote on everything they want to vote on," Cornyn said, adding, "What we're trying to do is convince everybody that if they'd like to get a vote on their amendment, then they need to vote to proceed to the House bill. "If the Tuesday vote fails altogether, senators say McConnell could try again on a later date, at which time Republican leaders believe conservative outrage over the failed vote could encourage senators who voted no to renew negotiations.

    The whip count

    Despite calls from both McConnell and President Trump to reluctant senators, as of Monday night there was no clear indication as to which scenario would play out. With McCain back for the vote, McConnell can afford to lose two Senate Republicans, with Vice President Mike Pence prepared to break a tie..

    Sen. Susan Collins (R-Maine) on Tuesday appeared to be a solid no, unless Senate GOP leaders come out with a brand new bill, "in which case I can't tell you," she said.

    Sen. Rand Paul (R-Ky.) said he would vote for a motion to proceed as long as Senate GOP leaders make clear they will proceed with a "clean repeal" bill. He said, "I'm not for 'we're not sure what we're going to.' "

    According to Politico, at least seven senators were undecided as of Monday: GOP Sens. Shelley Moore Capito (W. Va.), Rob Portman (Ohio), Cory Gardner (Colo.), Lisa Murkowski (Alaska), Mike Lee (Utah), Dean Heller (Nev.), and Jerry Moran (Kan.).

    Trump during two speeches on Monday urged Republican senators to support the vote, warning, "Any senator who votes against starting debate is telling Americans that you are fine with the Obamacare nightmare."

    Speaking at the White House Trump said, "Every Republican running for office promised immediate relief from this disastrous law. ... For Senate Republicans, this is their chance to keep their promise."

    Later that day, in a West Virginia speech before the National Boy Scout Jamboree, Trump called out Capito, saying HHS Secretary Tom Price "better get Senator Capito to vote for it."

    Democrats protest the upcoming vote

    Meanwhile, Senate Democrats held a so-called talkathon on the Senate floor Monday night during which they lambasted Senate Republicans' plan to move forward on their health reform proposals..

    Sen. Elizabeth Warren (D-Mass.) said, "When the goal is big tax cuts, it's hard to come up with something that actually also improves people's health care. The Republican health bills have gone from bad to worse to embarrassing."

    Sen. Chris Murphy (D-Conn.) said, "We are on the verge of taking a vote on a bill that objectively will rain a level of devastation down on this country that's really hard to fathom."

    Sen. Jack Reed (D-R.I.) said none of the options Senate GOP leaders have proposed are "acceptable, and I'm skeptical that my colleagues will be able to come up with a better solution in the next 24 hours" (Sullivan et al., "PowerPost," Washington Post, 7/24; Everett et al., Politico, 7/24; Kaplan/Hirschfeld Davis, New York Times, 7/24; Roubein/Hellmann, The Hill, 7/24; Carney, The Hill, 7/24; Collins, USA Today, 7/24; Nather/Baker, "Vitals," Axios, 7/25; Ehrenfreund, "Wonkblog," Washington Post, 7/25; Owens, Axios, 7/25; Sullivan, The Hill, 7/25).

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