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Why the Senate Republican health care bill has a vote problem

The biggest change proposed by the Senate Republican health care bill is how the federal government would fund Medicaid. Lisa Desjardins and Mary Agnes Carey of Kaiser Health News join Hari Sreenivasan to help break down the details and the political prospects for getting it passed.

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    We return now to the health care plan released today by Senate Republicans.

    To help break down the controversial details and politics, our own Lisa Desjardins, who's just returned from Capitol Hill, and Mary Agnes Carey of Kaiser Health News.

    Mary, let's start with Medicaid. How does this change what we know Medicaid to be?

  • MARY AGNES CAREY, Kaiser Health News:

    The biggest change is how we change funding, federal funding for the Medicaid program.

    Right now, states can spend what they need. It's matched on a percentage basis, but this would shift the Medicaid program to a capped allotment, a set amount of money. And so the thought is over time, would that allotment rise fast enough to meet the medical costs of the Medicaid population, and, if it doesn't, what do you do?

    Do you reducing payments to survivors? Do you have to cut services? Do you kick people off the rolls? That's one of the biggest concerns about this bill.


    But each one of these changes are political considerations. Who does this lure in to get those crucial yes votes?


    Well, we're really talking about those folks who are concerned about the debt and deficit, because the growth of Medicaid is a real concern for the federal budget. That's absolute.

    And for state budget as well. But it loses some votes potentially. There are a lot of senators, conservative Republican senators, whose states depend on Medicaid, who have high proportions of Medicaid users. Take Arizona. How about Ohio, some of these swing states, West Virginia.

    I talked to Senator McCain today. He said he's not deciding what he does until he speaks to his governor to see what this means for the state budget and for Medicaid. Also Alaska. A lot of these rural states, it's a real risk for them if they lose Medicaid funding.


    Are there structural changes to how Medicaid could be changing beyond just the expansion and how the payments go back?


    Well, in the sense of structural requirements, you could have work requirements, for example.

    Governors could do that. They could make those changes. And, again, this getting back to the growth and the payments, that is a big concern. Will it go fast enough? Will it meet the requirements of the Medicaid program, the spending?


    Think of the way that the Senate is doing it as, up front, they're going to let the expansion of Medicaid last a little bit longer. They ultimately would cut it, but they will cut, in the long run, 10 years out, the amount that Medicaid can grow by.

    So, in the short run, it's not as tough on Medicaid as the House bill, but in the long run, it ends up cutting a lot more than the House bill.


    But even with these measures, we saw Rand Paul today and said, well, I have got three other senators with me. We're not satisfied.


    Yes. That's right. They have a real vote problem here, because they can only lose two senators, as we reported earlier.

    And that's not just a Medicaid problem, but it's a problem from senators like Rand Paul who are concerned about tax credits and subsidies. This bill essentially keeps the Affordable Care Act subsidies intact structurally. It just reduces them.

    But Rand Paul, he says that's Obamacare-lite.

    I'm not sure how he will ever be satisfied unless they remove those subsidies altogether.


    Mary Agnes, we have also heard a conversation about meanness or whether this has enough heart. When we talk about the affordability of this, the quality of the coverage, how does this bill address those?


    Well, there's a couple things, to Lisa's point about the subsidies.

    They would be linked to income, like the Affordable Care Act, but also like age, which was the House bill. So, at the top end of the scale, there would be a little less generous, a little more generous at the lower end of the scale. But the other thing about this is, what is your money going to buy with the subsidy?

    The Senate bill would allow the plans to be less generous. Right now, the Affordable Care Act, the sort of middle-level plan that subsidy is based on, would cover 70 percent of the cost. Under the Senate discussion draft, that would drop to 58 percent.

    So, would you have to pay more? An older, perhaps a higher-income person, might pay more for less. And so that whole benefit of what you're getting for your money, that is going to be a big concern here.


    Mary, one of the things that President Trump has put on the table as a non-negotiable is preexisting conditions. That's something that was very popular from Obamacare, something a lot of people want to keep. How does this bill tackle it?


    Preexisting conditions would still have to be covered. But a state could get a variance from the set of essential health benefits. These are 10 things that have to be covered, mental health care, prescription drugs, maternity care.

    States could get a waiver from those. So, there is some concern, if a state could have plans that didn't cover prescription drugs or mental health care, what would that mean for beneficiaries? There is concern there.


    All right, one of the most divisive topics on this always comes down to Planned Parenthood funding, specifically around the cases of abortion.


    That's right. This was a late decision by the Senate leadership here.

    They went back and forth. There was a lot of discussion behind closed doors over this. And in the end, this draft right now would defund Planned Parenthood, all of their federal funding. That's over $500 million for that organization for one year. Instead of defunding it forever, it would be for one year.

    Now, that still is a very serious political problem, especially for two senators, Lisa Murkowski of Alaska and Susan Collins of Maine. We talked to both of them today. They said they haven't decided, but they are concerned about that. They said if that remains in the bill, and, again, there is a lot of negotiations now, Hari, if it's in the bill, they are going to propose an amendment to try and change it. That will be a fascinating vote on the Senate floor.

    We expect that. Speaking of it, that's what we need to watch right now. There's going to be a lot of horse-trading right now behind closed doors. Mitch McConnell is counting on it. This bill will change.

    After it changes, then there will be a process, we're told, next week of amendments. There will be a long day with a lot of votes. We will see how many of them pass. It really to me seems 50/50, Hari, right now on whether this gets through, certainly not as it is now. The question is, how will it change?


    And there are still constituents, Mary Agnes, that are on the sidelines saying, listen, covering opioid addiction is really important in my state, West Virginia and Ohio. There are people that going to be lobbying to try to get those in the bill.


    Well, that Medicaid expansion has funded a lot of opioid addiction treatment in Ohio, for example, and other states. And if that goes away, how are you going to help those folks? As we know, it's the number-one killer for Americans 50 and older now.


    They have put $2 billion in this bill to help with opioids, but those who are concerned say that's just a drop in the bucket and not nearly enough.


    All right.

    Lisa Desjardins, Mary Agnes Carey, thank you both.


    Thank you.

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