Senate Majority Leader Mitch McConnell has unveiled a revised version of the GOP proposal to repeal and replace the Obama administration's Affordable Care Act, but two members of his caucus have already voiced opposition to the bill. If another Republican lawmaker refuses to support the legislation, GOP efforts to replace the ACA would likely be dashed completely.
On July 13, McConnell revealed an updated draft of the Better Care Reconciliation Act during a private meeting with fellow Senate Republicans. The revised bill still ends Medicaid expansion and caps how much states receive in federal funding for the program, but contains several changes intended to appease Republican holdouts.
While McConnell adjusted the legislative draft to make it more palatable to his caucus, GOP Sens. Susan Collins of Maine and Rand Paul of Kentucky swiftly came out against the updated bill.
The revised BCRA would keep the ACA's investment income tax and payroll tax on wealthier Americans while increasing federal funding to combat the opioid epidemic from $2 billion to $45 billion. It would also allow Americans to use their health savings accounts to pay for their insurance premiums, The New York Times reports.
McConnell also inserted an amendment proposed by Sen. Ted Cruz. The Cruz amendment would allow for insurance companies to offer low-cost plans with minimal coverage as long as they also offered plans that meet ACA requirements to cover essential benefits.
The Cruz amendment has drawn fierce criticism from insurance companies. The American Health Insurance Plans asserted in a position paper that healthy Americans would flock to the cheaper plans, resulting in premium increases for those with pre-existing conditions.
"The exchange markets would basically function like a high-risk pool -- with unaffordable premiums for those with pre-existing conditions," AHIP warned, according to The Hill.
Cruz has signaled that he would not support the BCRA if his amendment was removed. Collins has already come out against the bill because of its cuts to Medicaid.
"My strong inclination and current intention is to vote 'no' on the motion to proceed," Collins told reporters after seeing the revised BCRA. The Maine senator said she would only change her mind if McConnell "fixed the Medicaid cuts, which I don't think that's going to happen."
Meanwhile, Paul has announced that he will not vote for the BCRA because he believes that it does not go far enough in repealing the ACA.
"I really can't describe my level of disappointment ... that bill does little to nothing to repeal Obamacare or fix our ailing healthcare sector," Paul wrote in an editorial for the Washington Examiner.
The GOP currently holds a majority of 52 seats in the Senate. McConnell needs at least 50 votes to pass the BCRA under budget reconciliation, a procedure that only requires a simple majority and could bypass Democratic opposition.
The Congressional Budget Office will release an estimate of the revised BCRA's impact on the U.S. health care system on July 17. The agency is running a separate analysis of how the Cruz amendment would impact health care. The CBO score of the original BCRA draft estimated that it would result in 22 million fewer Americans having health coverage by 2026 than if the ACA was kept in place.
On July 18, McConnell will hold a vote to begin a debate on the revised BCRA. If another Senate Republican joins Collins and Paul in opposition to the measure, the bill would effectively die.
"This isn't a vote on the merits of the bill," Republican Sen. Lamar Alexander of Tennessee told Politico. "This is a vote on whether to even to talk about it."
The Senate Majority Whip, John Cornyn, has asserted that his colleagues will either have to either set aside their objections and vote for the BCRA or allow the ACA to remain the law of the land.
"If you vote 'no' on this bill, it essentially is a vote for Obamacare because that's what we're going to be left with," Cornyn told Fox News. The Texas Republican added: "Unfortunately, the practicality is we have to pass a bill."