Four GOP Senators Threaten to Withhold Votes on ‘Skinny’ Repeal

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.

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