Providers ramp up pressure to scuttle Senate repeal bill

Healthcare industry groups opposed to Senate Republicans' Obamacare replacement bill plan to step up their lobbying of GOP senators now that Majority Leader Mitch McConnell has delayed a vote until after the July 4 recess.

McConnell announced Tuesday afternoon he was delaying a vote to proceed on the Better Care Reconciliation Act until senators return from the recess on July 11. He was stymied when GOP senators from Maine, Nevada, Utah and Wisconsin all said they would oppose a motion to begin debate. Under the Senate's budget reconciliation rules, he needs the support of 50 of the 52 GOP senators to pass the bill.

"The delay is good in the short run, but this bill isn't dead and probably will come back," said Margaret Murray, CEO of the Association for Community Affiliated Plans, which represents safety-net insurers. "We will continue to educate lawmakers about problems we see with the bill and its effect on low-income people and states."

On Tuesday, CEOs from 50 of her organization's members were in Washington meeting with their home state senators and representatives.

Arizona's two GOP senators, Jeff Flake and John McCain, face pressure from the state's providers and its Republican governor to protect the state's Medicaid expansion, which covers nearly 400,000 low-income adults.

"We're happy there's a delay," said Greg Vigdor, president of the Arizona Hospital and Healthcare Association. "We think the Senate bill is flawed policy, and we'll use the extra time to understand it better and urge our senators to oppose it."

It's expected that McConnell will try to negotiate changes with Republican moderates and conservatives who have expressed doubts about the bill, which was written by McConnell and his staff behind closed doors and unveiled last Thursday.

McConnell has nearly $200 billion over 10 years in enhancements to dole out to win over moderates concerned about the Congressional Budget Office's politically damaging report Monday. That report estimated the bill would lead to 22 million more Americans without insurance in 2026. The CBO also said that people buying coverage in the individual market would face significantly higher out-of-pocket costs under the bill, though some people would pay lower premiums.

Since the CBO scored the bill as saving $202 billion more than the House bill, McConnell could richen the bill's coverage provisions by that amount and still comply with Senate budget reconciliation rules.

Moderate Republicans like West Virginia's Shelley Moore Capito and Ohio's Rob Portman may press for a slower phase-out of the ACA's Medicaid expansion and additional billions in funding for substance abuse treatment for their drug-ravaged states. Conservatives like Utah's Mike Lee and Kentucky's Rand Paul want more rollbacks of ACA insurance rules, which they argue would bring down premium costs.

The majority leader is dancing on a knife edge. If he adds costly coverage enhancements to please the moderates, he risks losing the support of conservatives. If he relaxes insurance rules and weakens consumer protections, he could lose the moderates.

Murray said her organization is urging senators not to accept temporary grants for substance abuse treatment as a trade-off for phasing out Medicaid coverage.

"We don't want senators to think they've taken care of the problem by accepting a grant," she said. "Forty percent of medication-assisted treatment is paid for by Medicaid, and we want to make sure people have Medicaid coverage entitling them to treatment, not a limited pot of money."

Two moderates, Maine's Susan Collins and Nevada's Dean Heller, have said they can't support the Senate bill in its current form, while Paul has said the same thing from the conservative side. Heller, who faces a tough re-election campaign in 2018, is seen as a bellwether. If McConnell can win him over, many political observers think the bill will pass. But Heller has staked out a tough public position against cutting Medicaid.

For McConnell, the silver lining to the delay is it gives balky GOP senators time to publicly justify a switch from opposition to support, said Rodney Whitlock, a Republican healthcare lobbyist and former Senate staffer.

The downside is that during the recess break, Republican senators are going to hear a lot of fierce opposition to the bill—particularly to its restructuring and funding cuts in Medicaid—but not a lot of support. And the bill's provision locking people out from buying insurance for six months if they have a lapse in coverage will be a hard sell with the public, he warned.

"It will be harder and harder on members to hear all that from people and then come back to Washington and feel they're doing the right thing" by voting for the bill," Whitlock said.

Republican leaders want to pass their bill to repeal and replace the ACA as quickly as possible to so they can move on to tax and budget legislation. The Senate has 15 more working days before its long August recess. They have said that the end of July is the absolute deadline for the bill.

If McConnell makes changes to win over wavering senators, the bill will have to be evaluated again by the CBO and scored on its cost and coverage impact.

In addition, its provisions still have to be vetted by the Senate parliamentarian for whether they comply with budget reconciliation rules. That process could knock out nonbudgetary provisions such as insurance regulatory changes and bans on federal funding for Planned Parenthood and abortion coverage that are strongly supported by conservatives.

The bill's path looks rocky, but healthcare industry leaders aren't relaxing their guard, knowing McConnell is a savvy and determined legislative leader. They're particularly focusing their efforts on Senate GOP moderates who have expressed strong concerns about the bill's Medicaid provisions and coverage losses.

"We assume they'll make another run at the bill, just like when the House bill initially went down," Murray said. "We won't let up the pressure."