For the third time in three days, a majority of Republicans failed to coalesce around a way to repeal and replace Obamacare, as three centrist Republicans voted no on a "skinny repeal."
Sens. Susan Collins (R-Maine), John McCain (R-Ariz.) and Lisa Murkowski (R-Alaska) broke party lines to shoot down the Health Care Freedom Act, which landed at a 51-49 vote. The bill would have eliminated the individual mandate, as well as temporarily suspended the employer mandate and temporarily raised the amount of money that can be contributed pre-tax to health savings accounts.
McCain made his initial dissent public Thursday afternoon, holding a news conference with Sens. Lindsey Graham (R-S.C.) and Ron Johnson (R-Wis.) and saying the slimmed-down bill would "destroy" the health insurance marketplace. The three called for House Speaker Paul Ryan to guarantee the Senate proposal will go to conference rather than straight to that chamber's floor.
Ryan initially responded that the House was willing to work in conference with the Senate on the skinny bill, and further reassured the wary senators of his commitment in a phone call. Graham and Johnson then said they would vote for the bill as a way forward, while McCain called Ryan's initial statement "not sufficient," casting his "no" vote to the applause of Democrats.
It's unclear how the Senate will move forward on healthcare reform, as this was seen as the last, best hope to find consensus in a party divided on how to handle Medicaid and reforms to individual insurance. Senate Majority Leader Mitch McConnell said the Senate would focus on other legislation next week.
"This is a disappointment, a disappointment indeed," McConnell said on the Senate floor after the vote failed. "I regret that our efforts simply were not enough this time."
After urging senators to reject the "toxic" skinny repeal bill in favor of a bipartisan ACA replacement, the American Medical Association Friday morning reiterated that plea.
"While we are relieved that the Senate did not adopt legislation that would have harmed patients and critical safety net programs, the status quo is not acceptable," AMA President Dr. David Barbe said in a statement. "The first priority should be to stabilize the individual marketplace to achieve the goal of providing access to quality, affordable health coverage for more Americans."
McConnell (R-Ky.) told a group in his home state a few weeks ago that if Republicans failed to pass a repeal, the party would turn to Democrats to cooperate on shoring up the individual markets. In some rural counties in some states, no insurers have signed up to sell policies on the exchanges in 2018.
However, on the floor after the bill failed, he said, "Bailing out insurance companies with no thought of any reform is not something I want to be a part of."
Sen. Mike Rounds (R-S.D.) said he expects premiums in 2018 on the exchanges will rise at least 20% and up to 40% because cost-sharing payments "will probably not be available." When asked if he'd support a bipartisan push to appropriate the cost-sharing payments, he said, "We can always start, but the problem is the timing.
Vice President Mike Pence was in the Senate chamber Thursday night, but Rounds said he did not hear from Pence that the White House would cut off CSRs.
Sen. Lamar Alexander (R-Tenn.) has scheduled a hearing for the Senate committee that handles health matters, and that may be where the process begins. But it's not clear there are 12 Republicans who would be willing to spend more money to shore up a bill they have excoriated for seven years.
Sen. Amy Klobuchar (D-Minn.) said she has faith in Alexander's ability to get complex legislation done. She noted that Minnesota and Tennessee have added reinsurance to their ACA markets, and she said that should be a priority nationally.
Sen. Tom Carper (D-R.I.) said Democrats are "hitting the pause button," but the actions needed to stabilize the exchanges are known. Reinsurance, cost-sharing subsidies and making sure the individual mandate is enforced are the key actions, he said.
That will take work from more than just the Senate, as HHS and the Internal Revenue Service have backed away from enforcing the mandate this year.
"It's not up to just the two of us in the Senate," Carper said, gesturing to himself and Klobuchar. "The governors need to be speaking out, and they have been. Insurers need to speak out."
