Senate Republican leaders released a new Obamacare repeal bill Thursday that keeps some of the 2010 law’s tax hikes but further erodes its coverage mandates, allowing insurers to offer slimmer plans that could entice young and healthy Americans to sign up but raise costs for older and sicker customers.
The revised bill, though, has already lost support from the right in Sen. Rand Paul of Kentucky and from the center in Sen. Susan M. Collins of Maine, leaving Republicans with no extra margin for error ahead of a floor showdown next week.
A number of other senators are withholding their support and waiting to see what budget analysts say about the bill, but a defection by any of them, combined with Mr. Paul and Ms. Collins, would sink the repeal effort.
Two Republicans offered an alternative plan Thursday that would send Obamacare money to states and let them decide how to spend it, suggesting yet another option that could complicate the debate.
President Trump is pushing for a bill, saying he will be “very angry” if the Senate can’t pull it off, and leaders now say their troops face a binary choice: They can either vote for repeal or violate their 7-year-old pledge to do so.
“This is our opportunity to really make a difference on health care. This is our chance to bring about changes we’ve been talking about since Obamacare was forced on the American people,” said Majority Leader Mitch McConnell, Kentucky Republican.
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His new bill attempts to patch some holes in his first version, which was supposed to be an improvement over a House Republican bill that Mr. Trump had reportedly chided as “mean.”
Hoping to win over conservatives, Mr. McConnell included a version of a plan by Sen. Ted Cruz, Texas Republican, to let insurers offer both Obamacare-compliant plans and skinnier plans that would be cheaper for consumers balking at soaring premiums under Obamacare.
The bill also would keep Obamacare’s 3.8 percent tax on investment income and a 0.9 percent payroll tax hike on high earners. It also maintains Obamacare’s limit on the amount of executive pay that insurance companies can deduct from their taxes.
Republican leaders used some of that money to add to the “stability fund” they have created, which is designed to help insurers avoid heavy losses and to keep premiums in check. Another $45 billion would be invested in opioid addiction treatment — a key priority for Sens. Rob Portman of Ohio and Shelley Moore Capito of West Virginia.
Neither Mr. Portman nor Ms. Capito said how they would vote on the latest bill.
Ms. Collins, though, said the bill still siphons too much money away from Medicaid — costs she said would have to be picked up by states.
“It would hurt the most vulnerable citizens. It would have an adverse impact, particularly on our rural health care providers, our hospitals and our nursing homes, and it is not something that I can support,” she told reporters.
She said by refusing to craft the bill in an open committee process, they are making the same mistake that President Obama and congressional Democrats made seven years ago: jamming through a massive overhaul of health care without any support from the other party.
The biggest change in the bill is the adoption of Mr. Cruz’s plan to allow insurers to slim down their plans, freeing them from the long coverage list Obamacare required of every offering.
Republicans hope that would entice more young and healthy customers to maintain coverage. Insurance lobbyists condemned the idea, saying they need those customers to buy the more expensive plans on Obamacare’s exchanges in order to subsidize the costs for older, sicker customers.
Moderate Republicans are also skeptical, saying Americans with pre-existing medical conditions will have to pay more, though added stabilization money is designed to assuage their concerns.
Mr. Cruz says it’s better to subsidize insurers that take on people with pre-existing conditions with direct revenue than force healthy people to pay higher premiums.
Mr. Paul, however, said that would accelerate the type of entitlement spending that conservatives once pushed to eliminate. Ms. Collins said stability funding has been earmarked for several uses, so there might not be enough to go around.
Leaders placed the Cruz plan in brackets to signal that there is room to tweak the provision, though some Republicans want them to scrap it altogether.
“Allowing insurance companies to sell bare-bones, tax-credit-eligible, catastrophic plans would create a segmented insurance market and essentially return cancer patients, survivors and anyone with a serious illness to an underfunded high-risk pool where a patient’s out-of-pocket costs could be unaffordable and coverage potentially inadequate,” said Chris Hansen, president of the American Cancer Society’s lobbying arm.
Still, the Cruz measure is key to winning over other conservatives, including Sen. Mike Lee of Utah, who said he was still vetting the language.
Democrats remain unanimously opposed.
“The meat of this bill is exactly the same as it was before, and in some ways, they’ve somehow managed to make it even worse,” said Senate Minority Leader Charles E. Schumer, New York Democrat.
Some Republicans are floating an off-ramp from the current path.
Sen. Lindsey Graham of South Carolina pitched an alternative to the bill that he plans to offer as an amendment next week. In essence, it would let the states decide what to do with their share of the more than $100 billion in federal funding that is doled out each year under Obamacare.
Mr. Graham, a Republican, worked on the measure with Sen. Bill Cassidy of Louisiana.
“Instead of having a one-size-fits-all solution from Washington, we should return dollars back to the states to address each individual state’s health care needs,” Mr. Graham said. “Just like no two patients are the same, no two states’ health care needs are the same.”
• Tom Howell Jr. can be reached at thowell@washingtontimes.com.
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