After three days of debate and several fruitless votes on amendments, the Senate Republicans were unable to obtain enough support to pass their so-called “skinny” repeal of the Affordable Care Act.
Sen. John McCain, who recently returned from medical leave in Arizona to exhort his fellow senators to work together on reforming the healthcare system, was the deciding vote. He joined fellow GOP senators Susan Collins (ME) and Lisa Murkowski (AL) in voting against the bill.
With the GOP only holding a 52-seat majority in the chamber, these three votes were enough to ensure the demise of the Healthcare Freedom Act, the legislation introduced at the last minute by GOP leadership.
McCain had opposed the content of the “skinny” bill and said earlier on Thursday that he would only be willing to vote for it if he had a rock-solid assurance from House leadership that they would not immediately attempt to vote on the Senate bill. Instead, he and some other Republicans wanted a guarantee that the House would enter into a conference committee to work out a more amenable piece of repeal legislation.
Speaker of the House Paul Ryan made a vague assurances, but would not guarantee, a conference committee on the bill. While Ryan’s statement was sufficient for some on-the-fence Republicans, it was apparently not enough to get McCain out of the “no” column.
He ultimately signaled his disapproval with a thumbs-down gesture when his name was called. When the Senate clerk listed the “no” votes, there was an audible gasp in the Senate chamber when McCain was included in that group.
“Our efforts were not enough this time,” said Majority Leader Mitch McConnell after the vote, which ultimately went 51-49 against passing the repeal bill.
“We are not celebrating,” said Minority Leader Chuck Schumer. “Obamacare was hardly perfect. It did a lot of good things, but it needs improvement.”
At around 2:30 a.m. ET, President Trump used his preferred mode of communication to express his displeasure with the vote, blaming “3 Republicans and 48 Democrats” for the legislative failure and once again calling for lawmakers to “let ObamaCare implode, then deal.”:
What Was In The Bill?
Many people are probably waking up this morning not even knowing the name, let alone the substance, of the Healthcare Freedom Act.
The Senate Budget Committee released the bill [PDF] via Twitter shortly after 10 p.m. ET on Thursday night. We presume they were waiting to see who was evicted from Big Brother. (Spoiler: It was Ramses.)
The 8-page bill proposed the following:
• Negate the “individual mandate” — the requirement that all people must have some form of insurance or pay a penalty — by reducing the penalty for not having insurance to $0. This would have been effective immediately and retroactive to the beginning of 2016.
• Negate the “employer mandate” — the requirement that businesses of a certain size must provide full-time employees with qualifying coverage — by reducing the penalty for not having insurance to $0. This would have been effective immediately and retroactive to the beginning of 2016, but would have returned in 2025.
• Delay the tax on medical device manufacturers through 2020.
• Allow for increased maximums on Health Savings Accounts, starting in 2018.
• Deny federal funds to Planned Parenthood (or any similar program, but the definition is so specific that it’s really just Planned Parenthood) for one year.
• Shut down all funding to the Prevention and Public Health Fund, which provides funding to a variety of public health concerns, like Alzheimer’s research, diabetes prevention, heart disease prevention, anti-smoking initiatives, immunization, scientific support for state and local officials to detect and respond to outbreaks, and much more. This fund is about 15% of the entire budget for the Centers for Disease Control and Prevention. Funding would end starting in 2018, with no replacement offered.
• Allow states to seek “innovation” waivers. These waivers would give states the option of allowing insurers to not comply with several aspects of Obamcare, including the requirement that all plans must cover certain “Essential Health Benefits.” Once granted, these waivers can not be rescinded.
• Provide additional funding for the Community Health Center Fund for 2017. This money would have come from the funds that would have been taken from Planned Parenthood.
A Band-Aid Bill?
The GOP leadership has positioned the Healthcare Freedom Act as basically a procedural matter: Something at least 50 Republicans could vote on with the intention of sending the bill to a conference with the House of Representatives, where the finer details would be hashed out before passing a final version on to the White House.
However, Democrats and even some within the Republican party were concerned that this “skinny” bill was nothing but a pretense to get any repeal plan passed as quickly as possible — too quickly for some in the Senate.
Sens. McCain, Lindsey Graham (SC), and Ron Johnson (WI) publicly voiced their worries about the last-minute legislation on Thursday afternoon, hours before the text was even made available. Graham called the bill a “fraud” and a “disaster,” if it were to actually be passed on to President Trump, who had reportedly agreed to sign the legislation sight unseen.
Their concerns seemed to have some merit when it later revealed that House Majority Leader Kevin McCarthy (CA) had advised Republican representatives that they may have to declare “martial law” on Friday morning, indicating there could have been a rushed, immediate vote with no conference, and with the President signing as soon as this weekend.
McCain and the other bubble senators called on Speaker of the House Ryan to assure them that such a fast-lane vote would not happen, and that the bill would go to conference if it passed the Senate.
Ryan issued a response in which he acknowledged that sending the bill to conference was a possibility, but stopped short of guaranteeing it.
“If moving forward requires a conference committee, that’s something the House is willing to do,” said Ryan in a statement released Thursday evening. “The reality, however, is that repealing and replacing Obamacare still ultimately requires the Senate to produce 51 votes for an actual plan.”
This did not immediately appear to be sufficient for Graham, who said that if he doesn’t receive more concrete assurances from Ryan, he’s a “no” vote, though he ultimately turned his vote to “yes.”
It was apparently not enough for McCain, whose stirring speech on Tuesday afternoon called for more bipartisan participation on this and other issues. That said, McCain did vote against multiple motions from Senate Democrats to send healthcare reform back to committee where a true bipartisan reform of health insurance could be hammered out.
Same Old Score
The repeal effort was not helped when the Congressional Budget Office released a quick score of the “skinny” bill [PDF], effectively repeating its previous prediction that around 16 million additional Americans would end up without insurance as a result of this legislation.
Additionally, the CBO estimated that insurance premiums for policies in the individual marketplace would have risen by 20% above what the premiums charged under current law.
Larry Levitt of the nonpartisan Kaiser Family Foundation reviewed the bill and Tweeted out his views on the “winners” under the proposed legislation: those who will no longer have to pay mandate penalties; makers of medical devices; and large employers who don’t provide insurance coverage to workers. Losers under this proposal would be, according to Levitt, are middle-class families who have to buy their own insurance without the help of subsidies, and now face likely hikes to their insurance premiums.
“Toxic Prescription,” Says AMA
The American Medical Association, which has repeatedly come out against the repeal effort, did not hold back in its criticism of the “skinny” repeal bill, with AMA President David Barbe, MD, calling it a “toxic prescription that would make matters worse.”
Barbe predicted that the lack of an individual mandate — which insures that healthy Americans pay into the risk pool with the intention of providing care for as many people as possible — would result in higher premiums and further destabilize the insurance marketplace.
One of the big sticking points in previous Senate repeal bills were the planned cuts to Medicaid funding. Sens. Collins and Murkowski have both openly expressed concern about the impact that such changes would have on their constituents.
The “skinny” bill does not touch Medicaid directly, but there are some who still believe that not only was the repeal legislation prelude to future Medicaid cuts, but that repealing the mandates would still ultimately have a negative impact on Medicaid enrollment, particularly for children.
Joan Alker, the Executive Director of the Center for Children and Families at Georgetown’s Health Policy Institute, wrote on Thursday about what’s known as the “unwelcome mat” effect, the idea that repeal will discourage participation in Medicaid.
Not everyone who is eligible for Medicaid coverage is enrolled in the plan, sometimes because they don’t know they or their children are eligible. Alker points out that, even in states where Medicaid was not expanded to cover newly eligible families, there were increases in enrollment in the program from families who were encouraged to research their coverage possibilities and discovered they could receive Medicaid or CHIP benefits for their children.
She points to the huge slash in the number of uninsured children in Nevada in just one year: From an uninsured rate of 15% in 2014 to 7.6% in 2015.
“This is not because children by and large became eligible for something new as a result of the ACA. It is because enrollment in Medicaid for already eligible children went up,” explains Alker. This is the so-called “welcome mat” effect, but, according to Alker, the “skinny” repeal bill could roll out an “unwelcome mat” effect that “will result in fewer children and families having Medicaid coverage because participation rates in Medicaid will start moving in the opposite direction and start going down.”
Editor's Note: This article originally appeared on Consumerist.