Senate parliamentarian's ruling dims odds for new ACA repeal bill

A brewing Senate Republican effort to pass a new bill repealing and replacing the Affordable Care Act suffered a serious setback Friday when the Senate parliamentarian ruled that congressional authorization to pass such a bill with just 51 votes ends Sept. 30.

That means Senate Majority Leader Mitch McConnell would face the tough task of rounding up at least 50 votes—plus Vice President Mike Pence's vote—before the end of this month to pass a repeal-and-replace bill, which they were unable to do in July. Then, Senate Republicans would have to reach agreement with House Republicans, who passed their own bill. The two chambers would have to pass identical bills by the end of the month.

Republican Sens. Bill Cassidy of Louisiana, Lindsey Graham of South Carolina and Dean Heller of Nevada are working to build support among GOP lawmakers and governors for a plan to replace the ACA framework with a program of healthcare block grants to the states. Their plan, the details of which have not been released, would restructure Medicaid and likely reduce funding.

No Senate Democrats are expected to support their bill.

Experts said parliamentarian Elizabeth MacDonough's ruling that the fiscal 2017 budget reconciliation instruction for healthcare legislation expires on Sept. 30 significantly dims prospects for such legislation this year. The House and Senate approved that instruction in January.

"Having a fixed deadline of Sept. 30 would be quite tough even if there was nothing else on Congress' plate," said Sarah Binder, an expert on congressional procedure at George Washington University. "But there doesn't seem to be much of a coalition built for the Cassidy-Graham bill, and Republicans have to get into October without shutting down the government and defaulting on the debt."

There's nothing preventing Senate and House Republicans from approving a budget resolution for fiscal 2018 that creates a new reconciliation instruction enabling them to pass a healthcare bill with a bare majority. But Republicans also are determined to pass tax reform legislation through reconciliation.

Binder said passing up to three reconciliation bills during a fiscal year is permitted but is politically challenging. "It's a pretty heavy lift for a Republican Congress that's had a hard time getting anything big off the ground," she said.

There had been uncertainty whether MacDonough would rule that the reconciliation instruction ends Sept. 30, remains alive until Congress passes a 2018 budget resolution, or lasts until the end of this Congress next year.

Political observers predict it would be politically difficult for Republicans to pass a repeal-and-replace bill later this year or in 2018 as the midterm congressional elections get closer. That's because their legislative efforts have not proven popular.

A new analysis of public attitudes toward the GOP repeal-and-replace effort found that 58% of the public said the Affordable Care Act should be kept in place or kept and improved, while only 39% said it should be replaced with an alternative or not replaced at all. And 72% of those surveyed want to keep the number of people covered by Medicaid the same as it is now. The GOP bills would have sharply cut Medicaid coverage and funding.

Democrats cheered the parliamentarian's ruling Friday and said it points to the need for bipartisan action to improve and expand health coverage.

The Senate Health, Education, Labor and Pensions Committee is scheduled to hold hearings next week for the purpose of crafting legislation to stabilize the ACA-regulated individual insurance market. Republican Sen. Lamar Alexander, the committee chairman, and Democratic Sen. Patty Murray, the panel's ranking Democrat, say they'd like to pass a narrow stabilization bill by late September.

"Today's determination by the Senate parliamentarian is a major victory for the American people and everyone who fought against President Trump's attempt to take away healthcare from up to 32 million people," said Sen. Bernie Sanders, an independent from Vermont. "We need to work together to expand, not cut, healthcare for millions of Americans who desperately need it."