WASHINGTON - With time growing short, President Donald Trump and Republican Senate leaders are engaged in a frantic search for votes in a last-ditch effort to repeal and replace "Obamacare." The outcome is uncertain in a Capitol newly engulfed in drama over health care.
Here's what you need to know about Graham-Cassidy GOP healthcare:
Senate Majority Leader Mitch McConnell, whose failure to pass an Obamacare repeal bill in July opened a bitter public rift with Trump, is pressing hard for the newly revived effort, which had been left for dead as recently as a week or two ago. But in a sign he remained short of votes, McConnell refused on Tuesday to commit to bringing the legislation up for a vote.
As in July, much of the focus was on Arizona Sen. John McCain. Would he step back in line with fellow Republicans now that there was a bill co-written by Lindsey Graham of South Carolina, his best friend in the Senate? McCain wasn't saying. Lisa Murkowski of Alaska, another crucial vote, wasn't disclosing her views, either.
UPDATE: The Senate will vote next week on the latest bill to repeal Obamacare, a spokeswoman for Senate Majority Leader Mitch McConnell (R-Ky.) said Wednesday, per Politico.
Who wins, who loses in bill aimed at upending Obamacare
The GOP's last-ditch effort to repeal "Obamacare" would redistribute hundreds of billions of dollars in federal financing for insurance coverage, creating winners and losers among individual Americans and states in ways not yet fully clear.
Independent analysts say the latest Senate Republican bill is likely to leave more people uninsured than the Affordable Care Act, and allow states to make changes that raise costs for people with health problems or pre-existing medical conditions.
After closed-door meetings Tuesday, supporters seemed confident but acknowledged they're not sure if the bill can pass. There's only a narrow window for the Senate to act under special budget rules that expire at the end of the month.
The Congressional Budget Office has said it doesn't have time to complete a full analysis of the impact on coverage before the deadline.
The biggest changes would start in 2020 -- the next presidential election year. That's a political risk for Republicans, since health care changes often involve unforeseen problems.
A key feature of the legislation from Sens. Lindsey Graham of South Carolina and Bill Cassidy of Louisiana would put the ACA's financing for subsidized private health insurance and Medicaid expansion into a giant pot and redistribute it among states according to new formulas. States could obtain federal waivers allowing them to modify insurance market safeguards for consumers. For example, states could let insurers charge higher premiums for older adults.
The 31 states that expanded Medicaid are likely to see a funding reduction over time, as well as states, like Florida, where many residents received subsidies for private health insurance, said Larry Levitt of the nonpartisan Kaiser Family Foundation.
"Every state has to start from scratch creating its own health insurance program, in some cases with reduced federal funding and in some cases with increased federal funding," Levitt said. "I don't think at this point anybody knows what states are going to do."
Following the framework of previous Republican bills, the new legislation would also limit overall federal financing for Medicaid, which serves more than 70 million low-income people. That feature affects the entire program, not just former President Barack Obama's expansion to cover more low-income adults. It would change the current open-ended nature of Medicaid financing, a move that prompts deep concern from hospitals, doctors, nursing homes, consumer groups, and some state officials.
"The bottom line is most states will experience a reduction in federal funding under the bill," said Caroline Pearson of the consulting firm Avalere Health. "States that expanded Medicaid are likely to see some of the biggest cuts."
Graham says his bill will allow states to take the initiative on health care, designing programs that work best under local conditions. "I believe that most Republicans like the idea of state control of health care rather than Washington, D.C., control," he said. "We've come upon an idea that is uniquely Republican."
But Sen. Susan Collins, R-Maine, sees problems. "It seems that it has many of the same flaws as the bill that we rejected previously," said Collins, one of three GOP senators whose opposition derailed the last Republican legislation.
Here's a look at some winners and losers under the bill:
Winners -- People who don't believe the government should require individuals to purchase a costly private service like health insurance. The bill would repeal "Obamacare's" unpopular requirements for individuals to have coverage and for larger employers to offer coverage. The trade-off is that without such a legal requirement, more people are likely to be uninsured. And an accident or unexpected illness can make that a costly decision.
Losers -- People with health problems or with pre-existing medical conditions could be charged more if the state they live in obtains a waiver from current requirements that forbid insurers from charging higher premiums based on health status. States could also seek waivers from the current requirement that insurers cover 10 basic kinds of services, such as maternity and childbirth, or mental health and substance abuse treatment.
Winners -- Medical device manufacturers. The bill would repeal an ACA tax on the industry. But it would leave in place Obama's tax increases on upper-income individuals, a feature that may cause problems among some conservatives.
Losers -- States that expanded Medicaid, including 17 with Republican governors. The more generous federal match for the expansion would be phased out, and some of the money would be redistributed to states that did not expand their programs.
Winners -- People who use tax-sheltered health savings accounts for health care expenses. Contribution limits would be raised and consumers could use their accounts to pay insurance premiums, not just out-of-pocket costs such as copays and deductibles.
A last, last chance: Republicans strain for Obamacare repeal
Republicans must act by Sept. 30 in the Senate or face the prospect of a Democratic filibuster. That blocking action is currently staved off by budget rules that will expire at the end of the month. The new legislation, by Graham and Sen. Bill Cassidy of Louisiana, would undo the central pillars of former President Barack Obama's health care law, and replace them with block grants to the states so they could make their own health care coverage rules.
"Governors and state legislators of both parties would have both the opportunity and the responsibility to help make quality and affordable health care available to their citizens in a way that works for their own particular states," McConnell said on the Senate floor. "It's an intriguing idea and one that has a great deal of support."
Democrats are unanimously opposed, arguing that the legislation would result in millions of Americans losing their health insurance, decreased access to affordable care and a damaged Medicaid health program for the poor.
McConnell must win the votes of 50 of the 52 Senate Republicans. That would amount to victory in the 100-member Senate, because GOP Vice President Mike Pence would then break a tie.
Pence appeared at the Capitol on Tuesday and declared the Trump administration was "all-in" on the effort. The president himself was closely in touch with Graham and others.
If the bill does pass, Speaker Paul Ryan has committed to pushing it through the House as-is, and straight to the president's desk, according to Graham. After seven years of promises to get rid of Obama's law, Republicans would have finally succeeded. It would be a promise kept to the GOP base, yet one with uncertain and potentially devastating political consequences for the Republican Party given that millions of people would be likely to lose their health coverage and others might have skimpier care.
The bill would let states set their own coverage requirements, allow insurers to boost prices on people with serious medical conditions, end Obama's mandates that most Americans buy insurance and that companies offer coverage to workers, and cut and reshape Medicaid.
The bill's full impacts are difficult to predict because the Congressional Budget Office has not had time to assess it. But senators plan to move forward without a complete CBO "score," heightening outrage from Democrats.
By Tuesday evening the legislation remained at least one or two votes short.
The situation is nearly identical to where Republicans found themselves in July when McConnell made one last attempt to pass a stripped-down repeal bill. It failed in a tense late-night session, with McCain, newly diagnosed with brain cancer, casting the decisive "no" vote.
McCain finds himself once again at the center of the drama. But now there's a twist: His best friend in the Senate, Graham, is co-author of the bill.
McCain has been more more than willing to buck his party's leadership over the years, and to defy Trump. Undercutting Graham might be a different issue, and McCain brusquely refused to tip his hand Tuesday.
"I don't have anything to say," McCain said repeatedly, snapping at a reporter who pressed for more. "I have nothing to say, do you hear me?"
Graham made clear he was arguing the case forcefully to his longtime friend, with whom he's partnered on many policy initiatives over the years and rarely parted ways. A hearing on the legislation was scheduled for next week after McCain had complained there weren't any.
"I'm not speaking for Sen. McCain," Graham said. "I know he likes federalism, I know he wants bipartisanship, but I just don't personally see a bipartisan proposal that's got a snowball's chance in hell of doing anything other than propping up Obamacare."
Graham said: "It's either this or a march toward Bernie-care," a reference to Sen. Bernie Sanders' Medicare-for-all bill.
GOP Sen. Rand Paul of Kentucky has announced his opposition to the legislation, saying it doesn't go far enough in repealing Obama's law, while moderate GOP Sen. Susan Collins of Maine, who opposed earlier repeal bills, also sounded like a "no" Tuesday. She said the Graham-Cassidy bill could be worse than earlier versions because of potential harm to people with pre-existing conditions.
In addition to McCain, the focus was on moderate Murkowski, who was the third "no" on the earlier bill along with Collins and McCain.
Murkowski kept a low profile Tuesday but in what could be a significant factor for her, Alaska's independent governor, Bill Walker, joined a bipartisan letter with other governors in opposition to the bill, asking senators to instead focus on bipartisan approaches. A pair of potent interest groups, the American Medical Association and AARP, also declared opposition.
But the prospect for any kind of bipartisanship appeared to die altogether as GOP Sen. Lamar Alexander announced he had not found consensus in his attempt for a limited fix for existing health marketplaces. His Democratic partner, Sen. Patty Murray, accused the Republican leadership of freezing their effort.
Follow live updates from healthcare reporters from around the U.S. below:
McConnell's leadership faces fresh test on health care bill (CNN)
Sen. Mitch McConnell faces a key test of his leadership as he works to pass a last-ditch bill to repeal and replace the Affordable Care Act before a Sept. 30 deadline.
A victory would go a long way to silence his critics -- including President Donald Trump -- who charge the Senate majority leader failed to accomplish the top Republican promise to voters when the GOP-controlled Senate fell one vote shy of ditching Obamacare this summer.
It could also buffer the Kentucky Republican against grassroots detractors unhappy that Trump, in some instances, has started to go around GOP leaders on the Hill to cut deals with Democrats on fiscal matters and possibly immigration issues.
But a second loss on health care, which is very possible, could again raise doubts about McConnell's leadership and create new tension in his relationship with Trump at a time they need to join forces to advance a major tax overhaul and other legislation.
While momentum for the new repeal bill has gained sudden and unexpected momentum in the last week, it remains highly uncertain it can get the 50 votes it would need to pass, a threshold previous bills failed to reach despite months of intense negotiations. And McConnell's conference seemingly remains just as divided as before with several moderates from states that expanded Medicaid under Obamacare wary of the impact the new bill's block grant structure will have on their constituents.
"There is still a lot of work to be done," Sen. Shelley Moore Capito of West Virginia said after a closed-door meeting Tuesday where McConnell, Vice President Mike Pence and other supporters of the bill pitched reluctant members to get on board.
McConnell's allies in the Senate defended the leader's handling of health care. They noted that he lived up to his reputation as a great Senate strategist when he cobbled together 49 of 52 Republican votes for the repeal bill this summer, a feat one described as "remarkable" even though it failed.
Sen. Pat Roberts, R-Kansas, said he is concerned about "this whole business of overly criticizing the leadership."
But he acknowledged that it's hard to explain that to critics after the health care bill went down.
"When you're explaining, you're losing," he said.
"It's very complicated both substantively and politically," said Sen. Rob Portman, who is one of those Republicans weighing how the new bill will affect his home state of Ohio. "It falls on all of us not just Mitch McConnell."
Keenly aware that another defeat on health care could be politically disastrous and a major setback for the GOP's upcoming agenda -- including passage of the tax code overhaul -- McConnell went to great lengths to avoid promising a floor vote on the new repeal bill when he answered questions from reporters.
"If we were going to go forward we would have to act before September 30," he said. "We're in the process of discussing all of this."
Republicans took a detour from drafting the tax reform legislation last week when a fresh push to try again to repeal Obamacare grew organically from GOP rank-and-file members at a private GOP conference meeting. The bill was drafted outside of the GOP leadership and health care committee structure but McConnell and his leadership team have fully embraced it as they work to recover from their stunning defeat this summer.
GOP leaders know the stakes are high.
Sen. Roy Blunt of Missouri, a member of McConnell's leadership team, said regardless of what happens with the new health care bill, passing a tax bill is "critical" to Republicans maintaining their majority.
"I think a win is important for all of us but I think what we're doing with health care shows we're continuing to do our best," Blunt told CNN. "I do think win or lose on the health care vote, the tax vote is critical for us and our majority."
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