The latest Republican iteration of a bill designed to fulfill a major campaign promise for President Trump, the repeal of Obamacare, is likely dead after a fourth major Republican Senator, Susan Collins of Maine, has gone public with her disapproval of the bill. Currently, Senator Collins joins just a select few of her Republican colleagues in public opposition to the bill which is currently just shy of the number of votes needed for passage.
Senator Collins was previously considered to be leaning no on the proposal but now, after a public promise to vote against the bill which she described as “deeply flawed,” she will likely be the determining vote preventing passage of the Republican healthcare overhaul. In particular, the Senator from Maine found the bill’s proposed cuts to Medicaid as well as the removal of protections for people with pre-existing conditions to be deal-breakers for her support.
In a statement Collins released, she described the healthcare system as “a deeply personal, complex issue that affects every single one of us and one-sixth of the American economy,” a system that Collins believed should be reformed without haste, but rather with careful planning and thought. Collins continued, “sweeping reforms to our health care system and to Medicaid can’t be done well in a compressed time frame, especially when the actual bill is a moving target.”
The Republican healthcare overhaul, deemed “Graham-Cassidy” after its co-sponsors, Senator Lindsey Graham of South Carolina and Senator Bill Cassidy of Louisiana, could only afford to lose two Republican votes in order to garner a 50 vote margin and pass with a tie-breaking vote cast by Vice President Mike Pence.
Acting in his capacity as President Pro Tempore of the Senate, Vice President Pence’s tie-breaking vote on major legislation would certainly be an extraordinarily rare tactic, but not one without recent precedent as was the case in the confirmation of Education Secretary Betsy Devos. This would appear to simply be par for the course in pursuit for the passage of a bill that has already defied normal congressional process.
With only a 52 seat majority, the congressional Republicans only have until the end of the month to pass a healthcare bill through the Senate without Democrat opposition being able to filibuster through a legislative process called “reconciliation.” Budget reconciliation is a process that allows some fiscal measures to pass with a mere majority, rather than the usual 60 votes needed to overcome filibuster on major legislation.
Beginning in October, Republicans would need to secure the votes of at least 8 Democrats in order to move forward on healthcare legislation. This is at least part of why congressional Republicans have been acting in such a rush as they hastily press forward on a bill many of their own caucus have described as deeply flawed.
However, despite calls from Republican leadership for unity, the Graham-Cassidy bill has lost the support not only of moderates seeking a return to normal congressional order, like Collins and McCain, but also from a small contingent of the party’s far-right conservative bloc, Senator Rand Paul of Kentucky and Senator Ted Cruz of Texas.
Senator McCain opposition came first, just four days ago in a statement where he said that he could not “in good conscience” support the proposal while urging a return to normal congressional order and bipartisanship. The Graham-Cassidy bill has skirted nearly all of the standard legislative processes that proceed passage including public hearings, congressional debate, town halls to receive public feedback, and a full scoring of the bill, all processes which Obamacare underwent before passage.
With a narrow window of time and a ticking clock for the bill’s passage, the Congressional Budget Office stated that they will not have time to make a full analysis of the measure before a vote would need to take place. Nevertheless, after much congressional scrutiny and public outcry, the Graham-Cassidy bill’s received a “partial” CBO score, which officially arrived on Monday and is available to read in full below.CBO-Report-on-Graham-Cassidy-Health-Care-Bill
The nonpartisan Congressional Budget Office report concluded that “millions of additional people would be uninsured” under the Republican proposal, compared with the number of people uninsured under current law. It also deduced that “enrollment in Medicaid would be substantially lower because of large reductions in federal funding for that program.”
For some Republican Senators however, the bill’s cuts did not go far enough. Senator Ted Cruz of Texas said on Sunday that he had not yet been won over, however, he added that he was continuing to advocate for changes to the bill, ultimately hoping to vote in favor of the measure.
Others were less consolable than Cruz, Senator Rand Paul of Kentucky, a core member of the party’s staunchly conservative voting-bloc, denounced the Graham-Cassidy bill as a “fake repeal,” in a public statement and a Tweet.
Senator Paul opened himself up to the possibility of compromise on a more narrow “skinny repeal” proposal but rejected the bill’s core concept of providing block grands to individual states to use on healthcare. Senator Paul described voting for the bill as putting “your stamp of approval on a trillion dollars’ worth of Obamacare spending,” pushing instead for a more simple pure repeal. Any bill tailored to secure Paul’s vote would likely alienate more moderate members of the party, making passage difficult.
Without their own caucus in agreement, the clock is ticking for Republican leadership as they try to assemble a package that will garner the votes of at least 50 of their members before the October reconciliation deadline arrives. Attempting to win over key swing votes, the bill’s co-sponsors have added “sweeteners” for particular senators, like Alaskan Senator, Lisa Murkowski, who’s state would get 3 percent more funding between 2020 and 2026 in the latest version of the bill, and Senator Susan Collins from Maine, who’s state would net 43 percent more funding during that same time period.
While the sweeteners for her constituencies did not appear to be enough to secure Senator Collins’ vote, it remains to be seen whether they will be for Senator Murkowski, another necessary voter for the bill’s survival. Either way, the Republicans will still need to flip at least two of the Senators who is a public “no” vote in order to secure passage.
With Rand Paul’s staunch opposition to the bill’s current form and McCain’s rebuke of the process by which the bill is seeking to pass, Texas Senator Ted Cruz and Maine Senator Susan Collins’ appears the likely targets for Republicans to attempt to sway with added benefits for their states in the next iteration of the bill.
With time left for reconciliation dwindling on an unpopular bill that insurers, hospitals, doctors, patient advocacy groups oppose, the challenge for passage of Obamacare-repeal appears colossal.
Regardless, even while acknowledging it might fail, the bill’s architects vowed to “press on,” in a Monday night CNN debate on healthcare. Senator Graham added that “It’s O.K. to vote. It’s O.K. to fall short, if you do, for an idea you believe in.” The Republicans may only have belief at this point as realities have set in that make passage of Graham-Cassidy extremely unlikely.
Senator Graham also took to defending his colleague and friend, John McCain, from attacks leveled at him by President Donald Trump. Eyes brimming with tears, Graham reflected on the former Vietnam War hero who recently received a diagnosis of an aggressive form of brain cancer. Graham quipped that “John McCain can do whatever damn he wants to! He has earned that right.” Even Vermont Senator Bernie Sanders, a staunch progressive in opposition to the Republican bill who recently introduced his own single-payer universal healthcare solution, added in defense that he could not understand how Trump could attack McCain, who Sanders’ described as “one of the most decent people in the US Senate.”
Aside from the brief migration into the President’s comments, the CNN debate put Graham-Cassidy on public display, in a last-ditch effort to rally support behind the unpopular bill.
If Mitch McConnell and his fellow Republicans in leadership are unable to make inroads and use their clout to change the Senators’ votes, the Republicans’ hopes for Obamacare repeal will likely be dead for now and efforts to reform the healthcare system may shift towards a bipartisan approach to “fix” the flaws Obamacare.
Begrudging Bipartisan Compromise:
If Graham-Cassidy fails, the Senate will likely turn it’s attention back towards a bipartisan bill designed to repair problems in Obamacare and shore up individual state insurance marketplaces, a bill that had gained momentum and bipartisan support before being pushed aside by top Republicans to force through Graham-Cassidy instead.
Earlier in September, with Republican attempts at a Obamacare repeal bill dashed twice already and seeming futile, Republican Senator Lamar Alexander of Tennessee, the Chairman of the Senate Health, Education, Labor and Pensions Committee, and committee ranking member, Democratic Senator Patty Murray of Washington, worked together to forge a compromise between their two parties.
The result, a small, bipartisan bill attempted to prevent prices from skyrocketing next year and stabilize health insurance markets, which have suffered double digit premium increases across the country as uncertainty in the future of the Affordable Care Act has created doubts among insurers.
In particular, the bipartisan reform bill would see concessions from Republicans, who would agree to continued payment of subsidies to insurance companies to compensate them for reducing deductibles and other out-of-pocket costs for low-income people, and from Democrats, who would agree to give states the freedom to soften some of the insurance requirements in the Affordable Care Act. Senator Alexander described the concessions from both parties as something that they “may be reluctant to support,” before adding, “that is called a compromise.”
Several state insurance commissioners, including Mike Kreidler, the state insurance commissioner in Washington, the home state of Senator Murray who is one of the bill’s co-sponsors, urged Congress to establish a backstop measure for insurers under which the federal government would help pay the largest claims. The backstop, commonly called “reinsurance,” would be an effort they claimed would be the kind of “bold action” needed to shore up state insurance markets.
In exchange for support of more federal funding and support of state insurance exchanges, Republicans sought to ease the “cumbersome” process by which federal officials can grant waivers from some of the law’s requirements in order to encourage “innovating” state health insurance programs. Teresa D. Miller, the former Pennsylvania insurance commissioner, added “the more we could streamline that process, the better it would be” for consumers.
However, despite the momentum and cross-aisle support the bill received, it was eventually shelved in order to clear the way to uniformly push Graham-Cassidy instead.
With a bipartisan solution appearing like the only hope left for Republicans who seek to reform healthcare, it remains to be seen whether the bipartisan solution co-sponsored by Republican Senator Alexander and Democratic Senator Murray will be able to pick up where it left off.
Once the reconciliation deadline passes, eyes will be glued across Washington towards the stance of Democratic leadership. With the ball now in their court, time will only tell if the Democrats will return to the negotiating table or, feeling spurned, turn their backs in spite on the very Republicans, now freshly arrived from failure, for their earlier abandonment of a bipartisan solution.
Update – 9/26/17 at 6:30 PM:
It appears the Graham-Cassidy bill may be officially dead with Politico reporting that Senate Majority Leader Mitch McConnell will not put the bill up for a vote. Below are a series of comments that Senators gave Capitol Hill reporters on the state of the bill.
Cassidy: "We don't have the votes... Since we don't have the votes, we will postpone" vote on Graham-Cassidy bill— John Bresnahan (@BresPolitico) September 26, 2017
Sen. Kennedy on Graham-Cassidy: the bills dead. It's deader than a door nail— Leigh Ann Caldwell (@LACaldwellDC) September 26, 2017
• The News: The latest Republican iteration of a bill designed to fulfill a major campaign promise for President Trump, the repeal of Obamacare, is likely dead after a fourth major Republican Senator, Susan Collins of Maine, has gone public with her disapproval of the bill.
• The bill will need at least 50 votes to pass, with Vice President Mike Pence acting as an unprecedented tie-breaking vote on major legislation. This means the Republicans can only afford to lose the vote of two senators with their slim 52 vote margin.
• While Collins’ becomes the fourth senator to officially speak out against the bill, joining Senators McCain, Cruz, and Paul, she will likely be the determining vote as expectation is that Cruz will ultimately vote for the bill, something he himself stated his desire to do.
• The Graham-Cassidy Bill: While the Graham-Cassidy bill keeps much of the Obamacare infrastructure in place, at least immediately, it calls for dramatic shifts in the allocation and distribution of funding and ultimately, phases out federal funding entirely over a period of time.
• The Republican plan seeks to shift direct federal funding into “block grants” given to individual states to be allocated as they see fit, it also weakens protections for people with pre-existing conditions and softens requirements on mandatory coverage for so-called “essential health benefits,” which include maternity care, mental health services, and prescription drug coverage.
• The non-partisan Congressional Budget Office did not have adequate time before the planned passage of the bill to conduct a full CBO score but in a “partial” score released on Monday, it concluded that “millions of additional people would be uninsured” under the Republican proposal, compared with the number of people uninsured under current law, and that “enrollment in Medicaid would be substantially lower because of large reductions in federal funding for that program.”
• What Comes Next: Healthcare reform is still possible. However, if the Republicans miss the reconciliation window at the end of the month, they will be forced to work out a bipartisan solution like the one Republican Senator Lamar Alexander and Democratic Senator Patty Murray developed and gained momentum on just before it was shelved to push Graham-Cassidy.
• The prior bipartisan effort sought to offer insurers guarantees to shore up individual state insurance marketplaces. It required concessions from both Republicans, who would agree to continued payment of subsidies to insurance companies to compensate them for reducing out-of-pocket costs for low-income people, and from Democrats, who would agree to give states the freedom to soften some of the insurance requirements in the Affordable Care Act.
• After their efforts were tossed aside, time will tell if Democrats will opt to move forward on reform with their unpopular colleagues or, feeling spurned, seek to obstruct efforts that do not offer serious concessions.
• Future Problems for the Republicans: With one pair, Senators Collins and McCain and the other, Senators Cruz and Paul, opposing the bill, Republicans face internal dissent from both major wings of their party as both moderates and conservatives face off, with opposing demands. The Republicans will be hard-pressed to satisfy both camps on a compromise bill as shifting to appease one group will likely alienate the other.
• This could prove difficult more broadly for the Republicans as it creates a dynamic that will likely continue on any major legislation, jeopardizing their agenda going forward.
• Republican leadership will either need to find a delicate and precise balance, a “Goldilocks” solution on bills that satisfies both camps, or they will be forced to work with the Democrats to develop bipartisan solutions in order to garner the votes necessary to pass major legislation.
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