(CN) – Four GOP senators declared Thursday evening that they will not vote for a slimmed-down partial repeal of the Affordable Care Act without an iron-clad guarantee that the House will negotiate a comprehensive replacement in conference.
Sens. Lindsey Graham, of South Carolina, John McCain, of Arizona, Bill Cassidy, of Louisiana, and Ron Johnson, of Wisconsin tore into the so-called skinny bill, saying they’d rather see the health insurance market crash than for the skinny bill to be adopted, as is, as the replacement.
“The skinny bill as policy is a disaster,” Graham said. “The skinny bill as a replacement for Obamacare is a fraud.”
Graham and McCain both said the skinny bill is merely a vehicle to get the bill to conference and that it would in no way meet the needs of their respective states.
Graham said he needs assurances from House Speaker Paul Ryan “that if I vote for the skinny bill that it will not be the final product.”
“I’m not going to vote for a pig in a poke,” he said.
Graham said Rep. Mark Meadows, the leader of the conservative House Freedom Caucus, has told him he is concerned about a rising move within the House to simply take up the skinny repeal bill, which the Freedom Caucus does not support.
He said without those guarantees he would not support the skinny bill, which he warned would cause the collapse of insurance markets.
“The skinny bill is a vehicle to get in conference to find a replacement, it is not a replacement in and of itself,” Graham said.
Cassidy and Graham have offered a provision that would give roughly $500 billion in block grants over 10 years for states to use on state-specific health insurance programs. The plan would fund the block grants through taxes already in Obamacare.
Graham and Cassidy said they hope their plan would eventually become part of the final legislation in the conference committee.
The final vote on the skinny repeal plan is not expected until the early hours of Friday morning, though the timeline on the vote remains highly fluid.
Though the specifics of the skinny plan were not final as of Thursday afternoon, the so-called skinny repeal bill would likely repeal the mandates in the Affordable Care Act, better known as Obamacare, that require most people to have health insurance and that most businesses provide it for their employees. The plan could also touch on some of the law’s taxes and defund Planned Parenthood.
When asked about the specifics of the bill, Louisiana Sen. John Kennedy, one of the newest Republicans in the Senate, told reporters “it’s all still being discussed.”
The Congressional Budget Office on Wednesday night scored a hypothetical version of the bill that Democrats put together that would repeal the individual and employer mandates as well as a tax on medical devices.
The hypothetical bill the CBO scored, which is not an official proposal from either party, would also defund Planned Parenthood and a public health and community health center fund.
That plan would result in 16 million fewer people with insurance than under Obamacare, though Republicans have been quick to point out with previous CBO estimates that repealing the individual mandate would lead to some people simply choosing not to buy insurance. A senior Senate democratic aide said the CBO also told Democrats the skinny repeal bill would raise premiums by about 20 percent.
Matthew Beuttgens with the nonpartisan Urban Institute said there are three basic principles underlying the ACA that make it chug and without which the insurance market would suffer.
They are the same factors, he notes, that were woven into the Massachusetts health care law passed in 2006.
It guarantees coverage to all, gives tax credits and cost sharing reductions so that low-income families who would otherwise be locked out can buy insurance, and it requires individuals to be enrolled in health care coverage.
Take away any of those three components, and the market will suffer as a result, Buettgens said. That’s particularly true for the individual mandate.
“There will be an incentive for people to seek coverage when they believe they need care, or know that they need care, and drop it otherwise,” he said in a phone interview. “So that’s going to lead to healthier people enrolling less frequently. The risk mix will be much worse, there will be fewer people enrolled and premiums will rise.”
Because of the 2006 Massachusetts law, which sought to cover nearly all residents, Buettgens said there’s been more than a decade of research on this question.
“So there’s no doubt that lower coverage and higher premiums would be the effect,” he said of the possibility of repealing the mandate.
When asked to explain the importance of risk sharing, Buettgens said that’s the whole point – it pools risk across people.
“Regardless of what age you are, you’re a car accident away from being high risk,” he said. “There is a lot of risk involved in health care costs inherently. So that is why the insurance pool is so important.”
Essentially, the risk pool works best when most people participate.
Repealing the mandate, he said, would pose problems for stabilizing the markets. In the past, insurers dealt with that by denying coverage to people with higher health needs.
“So are we going back to that? Which that would be extremely unpopular,” he said.
Some Senate Republicans have said they would need to receive assurances from House leadership that the House would not pass the skinny repeal plan but send the bill to a special Congressional panel known as a conference committee, which is created to reconcile differences between the House and Senate versions of bills.
Texas Sen. John Cornyn, the number two Republican in the Senate, said requests to go to conference have to originate in the House of Representatives and that Senate Majority Leader Mitch McConnell and Speaker of the House Paul Ryan have talked about Ryan giving assurances that the House would allow the bill to go to conference.
That could be key to Republican leadership finally being able to deliver a win after multiple failed attempts to repeal Obamacare this week.
“I’m going to have to have some assurances that they’re not going to pass that,” Sen. Mike Crapo, R-Idaho told reporters. “I’m passing the skinny to get to a conference bill.”
Crapo said there is no formal mechanism for the House to give senators that promise and would not say whether he would vote against the skinny repeal bill if he was not satisfied the bill would just go to conference. Still, Crapo acknowledged that just repealing the individual mandate could cause problems with the insurance market, which would be the outcome if the House voted to send the bill to President Donald Trump’s desk.
Sen. Mike Rounds, R-S.D., told reporters that “more than one individual in the House” has said they will go to conference if the Senate passes the skinny repeal bill.
“This is strictly a vehicle to get into conference,” Rounds told reporters Thursday afternoon. “So, It’ll be whatever we can do to get to 51 votes so we can get it into conference, keep it alive, once again get the scores from CBO so that we can actually fix the mess we’re in.”
Republicans have already failed twice in the past two days to repeal Obamacare after Vice President Mike Pence broke a tie to bring the bill to the floor on Tuesday. The first attempt was on a version of the Republican replacement plan, which fell to a procedural motion on Tuesday night. Another plan that would have repealed the health care law with a two year delay failed on Wednesday.
Sens. Susan Collins and Lisa Murkowski have voted with Democrats on all three votes on the repeal measure, likely meaning Republicans cannot afford to lose another member on the skinny repeal plan.
The Alaska Dispatch News reported on Thursday that Murkowski’s no vote on the motion to move to the health care legislation earned her a call from Interior Secretary Ryan Zinke, who warned her and her and Sen. Dan Sullivan, who also represents Alaska, that the administration did not look kindly on her vote.
But Sen. Rob Portman, R-Ohio, buoyed the bill on Thursday afternoon with a tweet saying he would support it “to move this process to a House-Senate conference because I believe we need to repeal and replace Obamacare.”
The Senate has been considering its health care bill for two full days, with the amount of debate allowed on the bill set to expire Thursday evening. Once debate runs out, both parties will be able to offer unlimited amendments on the health care law, an event known as a vote-a-rama that is unique to the special reconciliation process Republicans are using the pass their repeal plan.