Senate Republicans pull plug for now on repeal bill

There will be no Senate vote this week on the Graham-Cassidy bill to repeal and replace the Affordable Care Act, Senate GOP leaders announced Tuesday.

That reportedly was a joint decision by Senate Majority Leader Mitch McConnell and the bill's two chief sponsors, South Carolina's Lindsay Graham and Louisiana's Bill Cassidy. They pulled the bill because they lacked enough votes to pass it.

Three Senate Republicans—Arizona's John McCain, Kentucky's Rand Paul and Maine's Susan Collins—all opposed the bill.

Despite the decision not to proceed with the bill this week, the repeal-and-replace drama may not be over. Some GOP senators are pushing to include the healthcare overhaul in a 2018 budget bill containing the Republican tax overhaul package, even though political observers warn that could jeopardize the tax bill.

McConnell needs the support of at least 50 of the 52 Senate Republicans to pass the bill under budget reconciliation rules requiring a simple majority. No Democrats support the bill. Authorization to use that procedure expires Sept. 30.

"We haven't given up on changing the healthcare system, we just can't do it this week," McConnell said at a news conference with Graham, Cassidy and two of the bill's other co-sponsors. Senate Republicans now will take up a tax reform bill, with markups next week, he added.

"We have 50 votes for the substance (of the Graham-Cassidy bill) but not for the process," Graham said. "I'm confident that with a new process, hearings and regular order, we'll get 50 votes."

Several Senate Republicans—including Alaska's Lisa Murkowski, who joined Collins and McCain in killing the previous GOP repeal bill in July—had not yet announced their position on the bill.

Murkowski declined to answer a reporter's question about how she would vote if a Senate vote were held. Over the weekend, the bill's authors added hundreds of millions of dollars in additional funding for Alaska in hopes of winning her support.

The bill would radically transform the healthcare system by converting the ACA's federal funding for coverage subsidies and Medicaid expansion into $1.2 trillion in block grant payments to the states through 2026, after which the funding would expire. Starting in 2020, states would have to create their own coverage schemes, with few limitations on what they could do.

That same year, the bill would convert the open-ended traditional Medicaid program into a system of per-capita federal payments to the states, with annual growth capped at the general inflation rate after 2024.

In a preliminary analysis, the Congressional Budget Office Monday said the revised Graham-Cassidy bill would reduce the number of insured Americans by millions. It also projected the bill would sharply increase premiums for people with pre-existing conditions and shrink availability of coverage for high-cost services such as mental healthcare and expensive prescription drugs.

That CBO analysis rebutted arguments by Cassidy, one of the bill's co-authors, that there was language preserving the ACA's protections for people with pre-existing conditions.

The CBO also said the bill would lead to major disruptions in the individual insurance market, at least initially, and would force most states to change the ACA's insurance market rules. That would include relaxing requirements that all plans cover an essential benefits package and refrain from basing premiums on enrollees' health status.

It predicted many insurers likely would leave the market due to the uncertainty, and that some areas probably would have no carriers selling plans until the new market rules were clear.

Federal Medicaid spending would be cut by about $1 trillion from 2017 through 2026, leaving millions fewer people covered, according to the CBO, which said it needed several more weeks to develop a full score for the bill. Funding to the states for the bill's block grants would be about $230 billion less over that period than current law would provide for premium and cost-sharing subsidies and Medicaid expansion, the agency said.

Democrats and some Republicans, including McCain, have expressed hope that as soon as the ACA repeal effort ends, the Senate health committee can resume its bipartisan initiative to craft a bill to stabilize the individual insurance market. That would include funding payments to insurers for the ACA's required cost-sharing reductions to low-income enrollees.

Insurers have said they need to know whether those cost-sharing reduction payments will be made to help them decide whether to offer 2018 plans and how to price them. The federal deadline for finalizing plans and rates is Wednesday.

"I hope Republican leaders will let us get back to work on lowering premiums and stabilizing the marketplace," Washington Sen. Patty Murray, the senior Democrat on the Senate health committee, said at a news conference Tuesday. "I'm ready to go."