San Antonio Express News: Senate unveils its Obamacare overhaul

WASHINGTON -- Senate Republicans, who've promised to repeal the Affordable Care Act for seven years, took a major step toward that goal, unveiling a bill Thursday to make deep cuts in Medicaid and end the mandate that most Americans have health insurance.

The 142-page bill would create a new system of federal tax credits to help people buy health insurance, while offering states the ability to drop many of the benefits required by the Affordable Care Act, like maternity care, emergency services and mental health treatment.

But the measure landed in rough seas ahead of a vote that Majority Leader Mitch McConnell of Kentucky wants next week.

Four conservative senators -- Ted Cruz of Texas, Rand Paul of Kentucky, Mike Lee of Utah and Ron Johnson of Wisconsin -- announced they'd would oppose it without changes.

Their votes are more than enough to bring it down.

"It does not appear this draft as written will accomplish the most important promise that we made to Americans: to repeal Obamacare and lower their health care costs," the four wrote in a joint statement.

The loss of four GOP senators could be fatal for the Better Care Reconciliation Act of 2017. With a 52-48 majority in the Senate, Republicans only can afford to lose two GOP votes, assuming Vice President Mike Pence would provide the tie-breaker in a 50-50 split. Democrats are uniformly opposed to the health care rewrite.

The dissenters' statement laid down a conservative marker: "There are provisions in this draft that represent an improvement to our current health care system, but it does not appear this draft as written will accomplish the most important promise that we made to Americans: to repeal Obamacare and lower their health care costs."

More moderate Republican senators, such as Dean Heller of Nevada, expressed their own qualms, as did the American Hospital Association, the American Cancer Society Cancer Action Network and the Association of American Medical Colleges.

"We are extremely disappointed by the Senate bill released today," the medical colleges association wrote. "Despite promises to the contrary, it will leave millions of people without health coverage, and others with only bare-bones plans that will be insufficient to properly address their needs."

Once promised as a top-to-bottom revamp of the health bill passed by the House last month, the Senate bill instead maintains its structure, with modest adjustments.

The Senate version is, in some respects, more moderate than the House bill, offering more financial assistance to some lower-income people to help them defray the rapidly rising cost of private health insurance.

But the Senate bill would make subsidies less generous than under current law. It would lower the income limit for receiving subsidies to cover insurance premiums to 350 percent of the poverty level, or about $42,000 for an individual, from 400 percent.

Older people could be disproportionately hurt because they pay more for insurance in general. Both chambers' bills would allow insurers to charge older people five times as much as younger ones; the limit now is three times.

The Senate measure, like the House bill, would phase out the extra money the federal government has provided to states as an incentive to expand eligibility for Medicaid. And like the House measure, it would put the entire Medicaid program on a budget, ending the open-ended entitlement that now exists.

It also would repeal most of the tax increases imposed by the Affordable Care Act -- a capital gains tax cut for the affluent would be retroactive for this year -- to pay for expanded coverage.

In effect, it would hand a broad tax cut to the affluent in a measure that also would slice billions of dollars from Medicaid, a health care program that serves 1 in 5 Americans, not only the poor but almost two-thirds of people in nursing homes.

The bill, drafted in secret, is likely to come to the Senate floor next week, and could come to a vote after 20 hours of debate.

Democrats and some insurers blame the Republicans and President Donald Trump for sabotaging the ACA, in part by threatening to withhold subsidies used to help pay for deductibles and co-payments for millions of poor people covered by the law.

And former President Barack Obama, who has been hesitant to speak up on political issues since leaving office, waded forcefully into the health care debate Thursday, saying the Senate proposal showed a "fundamental meanness" that would harm anyone who gets old, gets sick or starts a family.

"The Senate bill, unveiled today, is not a health care bill," Obama wrote on his Facebook page. "It's a massive transfer of wealth from middle-class and poor families to the richest people in America. It hands enormous tax cuts to the rich and to the drug and insurance industries, paid for by cutting health care for everybody else."

Texas Sen. John Cornyn, the Senate's No. 2 Republican, acknowledged the plan falls short of the long-term GOP goal of repealing Obamacare root and branch.

"We are constrained by budget rules, and we'll do the very best we can under the circumstances," he told Texas reporters on the eve of the plan's rollout.

He also blamed the Democrats for "being unwilling to lift a finger."

Democrats lined up to slam the bill, with Minority Leader Chuck Schumer of New York highlighting President Donald Trump's recent description of the earlier House bill as "mean." Schumer displayed a poster denoting the Senate bill is "meaner."

U.S. Rep. Lloyd Doggett, D-San Antonio, also recalled the president's words in a statement denouncing the bill.

"What Trump called a 'mean, mean, mean' bill just got meaner," he said. "If you expect to grow old, get sick or have a child, you're a loser under this bill. Older Americans will pay more and get less than now. Those with pre-existing conditions will likely be unable to buy affordable insurance. Working families who rely on Medicaid will be denied coverage. Women will lose control over personal health decisions through a bill drafted by a handful of Republican men."

U.S. Rep. Joaquin Castro, D-San Antonio, said the GOP proposal "would be a disaster for Texans. It was drafted in secret by just 13 guys in the Senate, and then made public only after getting lobbyists' approval. The bill will drive costs up, strip coverage for millions, and hurt senior citizens and working families the most."

In the short term, the possible electoral consequences are more muted in the Senate than in the House, as only two of the Senate Republicans who face re-election next year, Heller and Jeff Flake of Arizona, are seen as vulnerable.

But Republican leaders still must contend with internal divisions that will be difficult to overcome. Numerous Republican senators from states that expanded Medicaid are concerned about how a rollback of the program could affect their constituents, and they face pressure from governors back home.

Kevin Diaz and Bill Lambrecht of the Hearst D.C. Bureau contributed to this report.

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