This is unprecedented in modern American governing: Senate Republicans are hoping to vote on a potentially massive health care bill next week, despite a lack of hearings or any public indication of the details of their plan. As former Senate historian Don Ritchie told the Los Angeles Times, it has been a full century since the Senate has approached a major piece of legislation with such a closed and partisan process.
The reasons for this approach have to do with the complexity of the debate and the GOP’s slim majority in the Senate. Senate Republicans need 50 of their 52 members to agree on the bill. Republicans are still sorting out what combination of ideas will get them there, and they know that the more public the discussion is, the more likely it is that critics and senators may find new issues with the ideas on the table.
There is not yet a bill. But we do know a little about some key ideas in play behind closed doors.
The largest health care program in the country is currently the toughest issue for Senate Republicans to navigate, according to senators involved in the talks.
What is being discussed? 1) Phasing out the Affordable Care Act’s expansion of Medicaid, potentially over three years from 2020 to 2023, though some Republicans want a longer, seven-year phase-out. 2) Capping and reducing Medicaid funding. And 3) Possibly lowering the automatic growth rate for Medicaid in the future.
How do these ideas compare with the House GOP’s health care bill? Both proposals would significantly reduce the amount of federal money going to states to pay for health care for the poor. The House would end the Medicaid expansion more quickly. But overall, the Senate bill may end up cutting the Medicaid program more than the House, especially if the upper chamber cuts down the program’s automatic, inflation-related growth rate.
Unresolved? Many debates on Medicaid remain unresolved, but they include a furious battle over the funding formula for states. The question is whether states which have spent less on Medicaid should be rewarded for their efficiency with a preferential funding formula. Senators from high-cost states insist that efficiency is not the key factor, and that they need more funding. The issue could divide the GOP.
PRE-EXISTING CONDITIONS AND ESSENTIAL BENEFITS
What is being discussed? Senate Majority Leader Mitch McConnell, R-Ky., reportedly wants to keep in place protections for people with pre-existing conditions, but also allow states to end requirements that insurers cover some basic health needs, like hospitalization, mental health, and prenatal and childbirth care, that are known as “essential benefits.”
How does that compare with the House? There is a large difference between the chambers on pre-existing conditions. The House bill would allow states to remove cost protections for those with pre-existing conditions, so that insurers could charge their clients significantly more based on past illness and other medical conditions. However, the two chambers seem to be on a similar page when it comes to essential benefits.
What is being discussed? Multiple GOP Senate sources tell us that the bill is leaning away from blocking federal funding for Planned Parenthood. This is still under discussion, but at least two key Republican senators — Lisa Murkowski of Alaska and Susan Collins of Maine — have said they cannot support a bill that defunds the group. In addition, it is not clear that such a move would pass Senate rules for what can be in the bill and still get passed with just 51 votes.
How does that compare with the House? The House bill would defund Planned Parenthood. This issue could be a major sticking point for the two chambers if the Senate bill keeps Planned Parenthood funding in place.
What’s being discussed? Senate Republicans are talking about including some form of federal tax credit to help lower health care costs, especially for those struggling to afford insurance. The tax credit may differ based on age or income.
How does that compare with the House? The House has a similar concept in its plan, with tax credits ranging from $2,000 to $4,000 for people below a certain income.
Unresolved? The discussion in the Senate is reportedly continuing over whether this should be a flat credit; the same amount for most people who qualify; or something that rises as income drops.
What’s being discussed? Senate Republicans are mulling several other issues as they craft their health care plan. They include: potentially tens of millions of dollars to help curb the opioid crisis; a possible federal reinsurance pool for people with chronic illnesses; and significantly waiving or rolling back Obama-era insurance regulations.