As the Senate hurtles toward a potential vote next week to roll back the Affordable Care Act, Republican lawmakers still don’t know what legislation they will consider or what impact it could have on health coverage for tens of millions of Americans.
Senate GOP leaders have said senators may be voting to simply repeal major planks of the 2010 healthcare law, often called Obamacare, with no replacement.
Alternatively, Republican leaders suggested the Senate could consider a bill to repeal and replace the current law, even though that plan — which Senate Majority Leader Mitch McConnell (R-Ky.) unveiled two weeks ago — hasn’t been fully assessed by independent budget analysts.
Or the Senate could take up still another healthcare plan that McConnell hasn’t yet shown lawmakers.
The uncertainty so close to a major vote is feeding a growing sense of chaos on Capitol Hill, where GOP senators are openly fretting about the lack of information about legislation that could leave anywhere from 22 million to 32 million more Americans without health insurance.
"I don’t even know what we’re proceeding to next week," said Maine Sen. Susan Collins, a centrist Republican who has called on her party’s leaders to take a more measured approach to fixing the current healthcare law.
"I don’t know whether we’re proceeding to the House bill, a new version of the Senate bill, the old version of the Senate bill, the 2015 repeal-and-hope-that-we-come-up-with something-in-two-years bill. I truly don’t."
Sen. Bob Corker (R-Tenn.) compared the current Senate GOP healthcare discussions to a “bazaar,” with tens of billions of dollars being offered up to woo holdout senators. “I fear that it's beginning to lack coherency," Corker told reporters.
Friday afternoon, the Senate parliamentarian added to the uncertainty by determining that several major provisions of the plans McConnell has put forward in recent weeks do not qualify for the expedited procedures, known as budget reconciliation, which Republican leaders need to use in order to pass a healthcare measure with no Democratic support.
A provision that would deny money to Planned Parenthood, for example, cannot be included in the bill, the parliamentarian ruled, because it is a policy decision, not primarily a budgetary step. The same went for a provision designed to prevent consumers from buying health plans that cover abortions if they are using federal tax credits to help pay their premiums.
Both those rulings could complicate McConnell’s task because anti-abortion conservatives have said they would oppose the bill if it allowed any money to go to abortion providers.
The parliamentarian has not yet decided on several other provisions that could be key to certain senators’ votes.
The health of Sen. John McCain (R-Ariz.), who was diagnosed with a brain tumor and may have to miss crucial votes, also adds to the fraught nature of the vote count.
With a 52-48 majority and no Democratic support for repealing the current healthcare law, McConnell can afford to lose only two Republicans on any legislation.
Multiple GOP lawmakers have expressed deep reservations about each of the healthcare plans that the Senate leader has floated. And it remains unclear if McConnell will even have the votes to begin consideration of Obamacare legislation next week.
A spokesman for McConnell declined to say Friday what the Senate leader would ask lawmakers to vote on.
McConnell has said only that he wants a procedural vote to begin debate of the House-passed healthcare bill. He would then offer as yet unspecified alternative legislation, which senators would have an opportunity to amend through a series of votes.
But many senators are wary of starting the process without a clearer idea of what they will be considering.
Nor has President Trump provided much guidance.
This week alone, the president said the Senate should repeal Obamacare without a replacement; then he announced Republicans should just let the current law collapse; and then Wednesday, he urged GOP senators to go back to developing a replacement for the current law.
The confusion has made it next to impossible for independent analysts at the Congressional Budget Office to thoroughly analyze legislative plans that seem to be changing by the hour.
In the last two days, the budget office, or CBO, has released two new analyses, even as analysts acknowledged that the reports may not reflect what senators could be voting on next week.
On Thursday, CBO analysts said they still haven’t had time to analyze the impact of a crucial provision of McConnell’s Obamacare replacement bill, which would allow insurers to offer stripped-down insurance plans that do not have to offer basic benefits such as prescription drugs, maternity care and mental heath services.
Waiting for such an analysis isn’t necessary, Texas Sen. John Cornyn, the No. 2 Republican, told reporters at the Capitol on Thursday.
"That's a luxury we don't have," he said.
But the lack of details and analysis of the GOP’s plans are alarming patient advocates, physician groups and others who work in healthcare. Many are pleading with Senate Republican leaders to stop rushing to push through the legislation.
“When both sides of the aisle work together, they have always found the most durable and long-lasting solutions to the problems facing our country,” a coalition of 15 of patients groups said this week in a joint statement.
“We implore lawmakers to sit down in a bipartisan fashion and draft a new bill that will strengthen and expand access to affordable and adequate health care coverage.”
The coalition includes the American Diabetes Assn., the March of Dimes, the American Lung Assn., the National Multiple Sclerosis Society, the American Heart Assn. and the advocacy arm of the American Cancer Society.
On Friday, the American Medical Assn., the nation’s largest physicians group, sent a letter to Senate leaders calling for a stop to the repeal campaign. “We urge you to reject efforts to repeal or replace the Affordable Care Act and work instead toward improvements that will increase access to affordable, quality health care coverage for all Americans,” the group’s chief executive, Dr. James L. Madara, wrote.
Even budget experts sounded an alarm Friday, as eight former CBO directors, including three appointed by Republican Congresses, sent a strongly worded letter to congressional leaders cautioning lawmakers not to ignore the agency’s independent analyses of legislation, as the White House has urged Congress to do.
“Relying on CBO’s estimates in the legislative process has served the Congress — and the American people — very well during the past four decades,” wrote the former directors, whose tenures stretch from 1975 to 2015. “We urge you to maintain and respect the Congress’s decades-long reliance on CBO’s estimates in developing and scoring bills.”
The frenzied Senate process parallels the way House GOP leaders pushed through their bill rolling back the Affordable Care Act, which lawmakers voted on before the CBO had even analyzed it.
McConnell and other senior GOP senators once pledged that the Senate would take a more deliberative approach.
“We plan to take on the replace challenge in manageable pieces with step-by-step reforms,” the Senate leader said in January shortly after Congress convened
But now, just days before voting could begin, senators face vastly different options, none of which have been considered in committee hearings or debated openly.
The GOP plan to repeal the current law now and replace it later would leave an estimated 32 million more Americans without health coverage over the next decade, according to the latest CBO analysis.
At the same time, it would double healthcare insurance premiums by 2026, budget analysts concluded.
By comparison, the current version of McConnell’s plan to repeal and replace major parts of Obamacare now would increase the ranks of the uninsured by 22 million, the CBO estimated in its latest evaluation of that option.
The plan would lower insurance premiums on average, but largely because health coverage would become less comprehensive, and many older, sicker Americans would not get coverage because they couldn’t afford it.
Even that analysis is incomplete, however, as it doesn’t include a provision that McConnell has indicated he wants that would dramatically scale back what health insurers must cover.
That provision, sponsored by Sen. Ted Cruz (R-Texas), was not in the new analysis because the budget office needs more time to analyze it.
Many independent experts and health insurers believe that the Cruz proposal would be disastrous to health insurance markets and put coverage out of reach for millions of sick Americans.
Last week, the heads of the insurance industry’s two leading advocacy groups — America’s Health Insurance Plans and the Blue Cross Blue Shield Assn. — called that key provision of the Senate bill “simply unworkable,” warning it “would undermine protections for those with preexisting medical conditions.”
McConnell spokesman Don Stewart declined to say if the Senate leader would bring up legislation with the Cruz proposal even if has not been analyzed by the CBO.
Staff writer Lisa Mascaro in Washington contributed to this report.