Story was updated 6:35 p.m. ET.
Shortly after details surrounding the Senate Republican's healthcare reform bill dropped, so did predictions that changes would need to be made in order to sway some of the GOP's hold outs.
"If I had to predict, I would give a slightly better than 50% chance that the Senate adopts something," said Tom Bulleit, head of the health care practice in the D.C. office of Ropes & Gray law firm.
President Donald Trump almost immediately said he was open to making changes that might draw votes from conservative Senators who have said they might not vote for the Better Care Reconciliation Act of 2017 in its current form and three centrist Senators who are concerned with changes to Medicaid.
The Senate bill—which makes greater cuts to Medicaid than the House legislation—retains subsidies to buy insurance on the individual exchanges and a slower phase-out of enhanced funding for Medicaid expansion that Bulleit believes could help leadership line up moderate votes.
It would also allow Trump to claim this has more heart than the House bill.
Chiquita Brooks-LaSure, a managing director at Manatt Health, said if the bill clears the Senate, she gives it a more than 90% chance of passing the House.
But there are bill provisions likely to be cut, either because they don't survive the amendment process, or because they will be indefinitely delayed even if they become law.
Take the proposal aimed at evening out Medicaid spending across the country. The bill orders HHS to penalize states whose per enrollee spending is more than 25% above average, and to send more money to states whose per enrollee spending is 25% below average.
Those cuts are in addition to the per-capita cap plans that's in both the House and Senate bills. The House bill restricts the growth rate of federal match to medical inflation for most and adds one percentage point for disabled adults and the aged. The Senate bill does the same through 2024 and exempts disabled children from the caps entirely. The Senate bill then switches to standard inflation in 2025.
Caroline Pearson, senior vice president of policy and strategy at Avalere Health, said pegging the cap to standard inflation would blow such a large hole in state budgets, she thinks Congress will not do it when the time comes.
Another aspect of the bill that may be written into law, but never occur, is the Cadillac tax. That tax, one of many designed to pay for Obamacare, has been delayed repeatedly. In the Senate bill, it is repealed temporarily, but comes back at the end of the budget window.
"Under a Republican-controlled Congress and Senate, I'm not sure it ever bites," Bulleit said, but maybe it could be levied if there's a Democrat in the White House in 2026. He said changing the tax treatment of employer-provided insurance is universally loved by economists, and nearly universally hated by politicians. But, since the Cadillac tax "is a baby step, I don't consider it dead in the water."
I think we are setting up a system of temporary fixes, Pearson said about the future move to a cap based on standard inflation.
Brooks-LaSure is less sanguine. She said thinking a future Congress will adjust it — I just don't think that's something we can bank on.
