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Health Bill Faces Challenges From Senators, Budget Analysts

The House passed its version this month, but not without difficulty, and now Republicans who run the Senate are finding hurdles, too



    (Published Wednesday, May 10, 2017)

    Remember the Republican health care bill?

    Washington is fixated on President Donald Trump's firing of FBI chief James Comey and burgeoning investigations into possible connections between Trump's presidential campaign and Russia.

    But in closed-door meetings, Senate Republicans are trying to write legislation dismantling President Barack Obama's health care law. They would substitute their own tax credits, ease coverage requirements and cut the federal-state Medicaid program for the poor and disabled that Obama enlarged.

    The House passed its version this month, but not without difficulty, and now Republicans who run the Senate are finding hurdles, too.

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    A look at some of those obstacles and what senators are trying to doing about them:


    GOP senators say they're discussing a possible short-term bill if their health care talks drag on. It might include money to help stabilize shaky insurance markets with subsidies to reduce out-of-pocket costs for low-earning people and letting states offer skimpier, and therefore less expensive, policies.

    It's unclear Democrats would offer their needed cooperation, but Republicans are talking about it.

    "We've discussed quite a bit the possibility of a two-step process," said Sen. Lamar Alexander, chairman of the Senate Health, Education, Labor and Pensions Committee. "In 2018 and '19, we'd basically be a rescue team to make sure people can buy insurance."

    That could mean Republicans might even temporarily extend Obama's individual mandate — the requirement that people to buy coverage or face tax penalties. It's perhaps the part of Obama's law that Republicans most detest. But it does prompt some people to purchase insurance, which helps curb premiums and make markets viable.

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    Alexander, R-Tenn., said there's a "strong bias" to address short- and long-term problems in a single bill.

    "If we can't do the real thing, we'd have to do the next best thing," Senate Finance Committee Chairman Orrin Hatch, R-Utah, said of short-term legislation.


    Because Democrats oppose the repeal effort unanimously, Republicans will need 50 of their 52 senators to back their overhaul so Vice President Mike Pence's tie-breaking vote would clinch passage. GOP senators show no signs of producing a bill soon.

    Time is important, especially with Trump's problems distracting lawmakers. Insurance companies could grow increasingly spooked by the uncertainty and make health care markets even worse by raising premiums or pulling out.

    Also, the longer it takes Republicans to write the legislation, the less time they'll have for tax cuts and other GOP priorities.

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    The House version would end in 2020 the extra federal payments that states get under Obama's law for expanding Medicaid to additional people. Senate conservatives prefer to start phasing out that money next year. But 20 GOP senators come from states that expanded Medicaid and want to protect those voters, so many would rather reduce the payments over many years.

    Conservatives and moderates are also bickering over how tightly to cut future spending on the entire Medicaid program.

    Many Republicans want to refocus the House's health care tax credits, which grow with people's ages, by boosting subsidies for lower earners. Eager to reduce premiums, many want to roll back Obama mandates such as requiring insurers to cover specified services, including substance abuse counseling, but there are questions about how far to go.

    Decisions await on helping states subsidize people with costly medical conditions and keeping insurers from fleeing unprofitable markets.

    Making Medicaid, the tax credits and other programs more generous than the House will cost many billions of dollars. Senators will need ways to pay for that.

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    The Congressional Budget Office plans to release its estimate Wednesday of the House health care bill's cost and how it would affect coverage. Those numbers will give senators a starting point and could be a big deal.

    Congress' nonpartisan budget analyst projected in March that an earlier House version would mean 24 million additional uninsured people. That scared off many Republicans and complicated House leaders' job of passing their legislation.

    Senators will examine whether the House bill still cuts Medicaid by $840 billion over a decade and reduces taxes — largely on higher earners and health industry sectors — by around $1 trillion. Democrats targeted both reductions as unfair.

    Also being watched is whether a number of late changes in the House bill will force the House to vote again on the legislation. That would be a major problem for the GOP, which nudged the measure through the House by four votes.

    The budget office said the earlier House bill had $150 billion in 10-year deficit reduction. But that was before House leaders added extra money and provisions letting states reduce coverage requirements to win votes.

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    Congress approved special rules that will block Democrats from using a Senate filibuster to kill the health bill. To retain the filibuster protection, the bill that the Senate receives from the House must reduce the deficit by at least $2 billion, including $1 billion each from two Senate committees, over a decade.

    If the final House bill doesn't meet those targets, the filibuster protections will vanish unless the House approves a new version that does.

    That wouldn't be easy.