With the July Fourth holiday recess fast approaching, divisions among Republican senators trying to craft a healthcare reform bill are becoming even more pronounced and questions are swirling on whether a bill can be finalized over the next two weeks.
Sen. John Thune (R-S.D.), third-highest ranking member in the GOP leadership, told reporters that there's a 50-50 chance the Senate will finish work on a bill by then. John Cornyn (R-Texas) told the Associated Press that the end of July is a more reasonable deadline.
Nonetheless, Senate Majority Leader Mitch McConnell (R-Ky.) is reportedly still pressing for a vote before the recess. While he faces an uphill battle to unite various factions of his own party, one need only consider the last-minute negotiations that salvaged the American Health Care Act in the House to realize that anything is possible.
Front and center for McConnell is the split between senators on Medicaid funding.
The House bill, which passed with just a four-vote margin, would end the federal match for Medicaid services, and replace it with a set amount for each recipient. The elderly and disabled would have that amount grow 1 percentage point faster than children and the able-bodied. House GOP leaders said the per capita cap for the latter group would be pegged to the medical component of the Consumer Price Index.
Medical inflation in 2016 was 3.8%, but has varied widely in the last 10 years, from 2.4% to 4.4%. Per capita spending in Medicaid fell by 5.1% in expansion states in 2014, according to the most recent data available from the CMS. That's because the expansion population is healthier than the traditional Medicaid population. In non-expansion states, per-enrollee spending climbed by 5.1%.
Since drafting of the Senate bill is being done behind closed doors, it's unknown whether the growth rate will be more or less generous than medical inflation.
Sen. Dean Heller (R-Nev.) has made it clear both in hearings and in hallway interviews that he cannot support a bill that caps growth at a slower rate.
"I just don't want to do worse than what the House did. And there's a push to bring it below the House, so that's an issue," Heller told Roll Call. At a recent budget hearing, Heller tried to get HHS Secretary Dr. Tom Price to project how fast he expects costs to grow over the next 10 years. Price said he did not have that exact number "on the tip of my tongue."
That's critical to judge whether the rate at which Congress allows the per capita contribution for Medicaid to grow will leaving states holding the bag. If it grows at the rate of medical CPI, will that be fast enough? Will medical CPI plus 1 percentage point be fast enough for the aged and disabled, who consume 40% of Medicaid spending?
"I'm trying to get an answer to this question; I can't get any out of our meetings," Heller said.
Heller's vote is considered critical, as is Alaska Sen. Lisa Murkowski's backing. Vote counters expect leadership to lose Sen. Rand Paul of Kentucky, and in order to pass a bill, they can only afford to lose one other, on the right or in the center.
But to get Heller's vote on the rate of growth, bill drafters could easily lose other Republicans, and not just those considered most conservative in the caucus.
Sen. Lindsay Graham (R-S.C.) said this week that the Senate bill will have income-based subsidies for the marketplaces, which is more generous than the House bill. When asked if the Senate bill will have a lower per capita cap growth rate than the House bill, at first he said he didn't know. He added: "They have to, or it won't make no sense at all."
President Donald J. Trump invited 15 Republican senators to lunch Tuesday, and, according to people who were there, called the House Obamacare replacement "mean."
Graham said, "I just think the House had to pick up the Freedom Caucus votes and they want to control the escalating cost of Medicaid. ... I don't consider what they did mean, I just don't think it's gonna pass the Senate. You know, at the end of the day, I think Obamacare's sort of been mean. It's thrown a lot of people off coverage they had, driven up costs."
Modern Healthcare asked Sen. Bob Corker (R-Tenn.) if the Senate bill keeps about 80% of the House approach. "I've never seen a draft," he said, and chuckled. "So it'd be hard for me to say whether it's 80%, 5%, 90% or 1%. I just don't know."