Senate Votes to Debate, Redo ACA Repeal

July 25, 2017

The Republican-controlled Senate today voted along party lines to resume debating how to fulfill their long-standing promise to repeal and replace the Affordable Care Act (ACA).

Vice President Mike Pence cast his vote to break a 50-50 tie in favor of the GOP.

Sen. John McCain (R-AZ), recently diagnosed with brain cancer, interrupted his recovery from an emergency craniotomy for removal of a blood clot to cast his vote and help his party win after legislative impasses earlier this month.

Of the 52 Republicans in the Senate, only two joined 46 Democrats and two independents in voting no — Sen. Susan Collins (R-ME) and Sen. Lisa Murkowski (R-AK).

Technically, the Senate approved a motion to debate a House bill, passed in May, that would dismantle much of the signature legislation of the Obama administration. However, Senate Majority Leader Mitch McConnell (R-KY) intends to use the House bill, called the American Health Care Act (AHCA), as an erasable legislative blackboard on which his colleagues can write yet another version of healthcare reform 2.0, one that can win a simple majority for passage.

Through the amendment process, Senate Republicans could convert the AHCA into a repeal-and-replace bill that resembles their own Better Care Reconciliation Act (BCRA). Or they could gut all the provisions of the House bill and substitute a repeal of the ACA, with a 2-year delay that would allow lawmakers to devise a replacement plan in the meantime. A Republican-controlled Congress passed such a measure in 2015 only to see President Barack Obama veto it.

A third option is to craft a stripped-down version of ACA repeal that eliminates tax penalties for individuals who do not obtain health insurance coverage, and for employers who do not offer it, and the law's tax on medical device makers, as The Hill reported today.

The goal is for the Senate Republicans to secure at least 50 votes — with Vice President Pence serving as a tiebreaker — and send whatever legislation they produce to a House-Senate conference committee. There, Republican lawmakers will attempt to hammer out a compromise measure that can pass both chambers.

That final legislative outcome faces daunting prospects in light of deep splits among Republicans on what the ACA's replacement should look like. Some Republican moderates who want to preserve coverage gains achieved under the ACA have withheld "yes" votes for the BCRA. That Senate bill would reduce Medicaid outlays by 26% by 2026, add 22 million more Americans to the ranks of the uninsured by that time, and most likely increase deductibles for plans sold on non–group insurance marketplaces, or exchanges, according to the Congressional Budget Office (CBO). The number-crunching agency estimated that the bill would reduce the federal deficit by $420 billion over 10 years.

The House-concocted AHCA would save a net $119 billion and increase the number of uninsured by 23 million by 2026, according to the CBO.

A new version of the ACA repeal bill that Congress approved in 2015 would leave an additional 32 million Americans uninsured by 2026 and reduce the federal deficit by $473 billion over 10 years, the CBO found.

The Drumbeat of Criticism From Organized Medicine Continues

A number of major medical associations have consistently opposed Republican proposals this year to repeal and replace the ACA, asserting that they would strip healthcare coverage from those who need it the most. Today, six of those groups pleaded unsuccessfully with the Senate in a letter to vote against the motion to begin debate on repealing the ACA or replacing it with a plan that would "eliminate access to care for tens of millions of patients."

"This is dangerous and unacceptable," wrote this coalition of medical societies, which consisted of the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians (ACP), the American Congress of Obstetricians and Gynecologists, the American Osteopathic Association, and the American Psychiatric Association (APA).

The drumbeat of criticism continued after today's vote. APA CEO and Medical Director Saul Levin, MD, said in a news release that Republican proposals to end Medicaid expansion under the ACA would hurt roughly four million individuals with serious mental illnesses and substance-abuse disorders who have gained coverage for the first time under the program.

ACP President Jack Ende, MD, said his group was "gravely disappointed" with the Senate's decision to start debating "still-secret legislation that could result in tens of millions losing insurance coverage."

And "extremely disappointed" was the reaction of Darrell Kirch, MD, the president and CEO of the Association of American Medical Colleges.

Follow Robert Lowes on Twitter @LowesRobert

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