Since the start of the 115th Congress, both the executive and legislative branches of government have been under single party control. The US House of Representatives, under the leadership of Speaker Paul Ryan (R-WI), and the Senate, under the leadership of Majority Leader Mitch McConnell (R-KY), with the backing of the Republican White House, have been fully engaged in repeal and replacement of the Affordable Care Act (ACA).

Once the process began in earnest, principal concerns came from Republicans who believed that the new health care bill should include provisions 1) to provide coverage for people with pre-existing conditions, 2) for those with employer-based health insurance, and 3) for cuts to Planned Parenthood. Democrats flatly rejected the bill saying that, in particular, its Medicaid cutback provisions would hurt too many elderly and poor Americans by eliminating Medicaid expansion eligibility included in the ACA. Democrats also complain the bill may cause unnecessary spikes in premiums for low-income families, older Americans, and those with pre-existing conditions.

The Medicaid Debate

Chief among concerns is the gradual elimination of the ACA Medicaid Expansion Program eligibility written into the new Republican House and Senate Bills. Both the Senate and House bills phase out extra money that the federal government has provided to states under ACA as an incentive to expand eligibility for Medicaid. More importantly, this means that seniors would receive fewer health care benefits under the new Senate and House bills.

What is Medicaid (not to be confused with Medicare)? It is a government funded health care program that provides health insurance to people with disabilities, the elderly, low-income seniors, and families with children and pregnant women. It helps pay medical expenses for those who cannot afford comprehensive medical coverage. Medicaid is financed by both federal and state governments. However, each state manages its own Medicaid program and decides its own rules for participation.   

What is Medicaid Expansion? The federal government website Medicaid.gov defines the program as expanded eligibility coverage under ACA for the poorest Americans. ACA created an opportunity for states to provide Medicaid eligibility, effective January 1, 2014, for individuals under 65 years of age with incomes up to 133% of the federal poverty level (FPL). For the first time (under ACA), states could provide Medicaid coverage for low-income adults without children with guaranteed coverage through Medicaid in every state without need for a waiver.

House Deliberations 

After a month of wrangling, the new health care bill was withdrawn from consideration due to moderate and conservative Republicans who threatened not to vote for it until outstanding issues were resolved.

In the House, the Congressional Budget Office (CBO) score was not released until after the bill passed. The eventual nonpartisan score showed that 15-23 million Americans could lose their health care benefits by 2026, more than if Obamacare remained intact. The new American Healthcare Act (HR 1628) passed the House May 4 by a vote of 217 to 213.

After House passage, the bill moved to the Senate. Senators agreed to disagree with significant elements of the House bill and decided to totally rewrite it. As the House moved expeditiously to put a bill in place, the Senate worked behind closed doors with 13 Republican Senators drafting a revised bill. There was major concern over the bill being drafted without a CBO score analyzing its cost. The Senate decided to delay releasing its bill until all the pieces are in place.

Democratic Senators protested because the bill was not subject to committee hearings or debate on the floor. Now, Republican senators who heard from angry constituents at town hall meetings during their recess are carefully considering their options. Meanwhile, political pundits continue to calculate the impact of possible losses of Republican seats if the bill is signed into law without the support of voters.

The Senate bill was recently released with deep cuts to Medicaid and ending the ACA mandates for purchasing insurance, maternity care provisions, emergency services, and mental health treatment.

Now that the July 4 holiday recess has ended, the Senate is moving toward a full vote in the chamber. As of this writing, four Republican Senators will oppose it: Rand Paul (KY), Ted Cruz (TX), Mike Lee (UT), and Ron Johnson (WI). Cruz has introduced his own amendment that is now under consideration. Vice President Mike Pence, President Donald Trump, and Mitch McConnell are negotiating hard with reluctant Senate members to move the bill forward as opposition voices continue to grow from Members like Susan Collins (R-ME). Further complicating forward progress on the vote is the absence of Senator John McCain who recently had eye surgery and will be away from Washington for approximately two weeks. Failure to hold a vote could mean that no bill would pass this year, leaving the ACA as the “law of the land.”

The White House continues to weigh in with uncommitted Republicans suggesting that Trump would like to see the outstanding issues resolved and have a bill in place and ready for his signature before congress takes its August recess. At this writing, less than three weeks before August 1, few members of Congress have hope that an agreement can be reached in time. Some in leadership are beginning to believe that the best chance they have for passage of the Senate bill is to reach out across the aisle and include Democrats in the negotiations. Trump has now suggested that the Senate consider first repealing the ACA and then replacing it. Not all members of Congress support that solution.