Trump to end key ACA subsidies, a move that will threaten the law’s marketplaces



President Trump is throwing a bomb into the insurance marketplaces created under the Affordable Care Act, choosing to end critical payments to health insurers that help millions of lower-income Americans afford coverage. The decision coincides with an executive order on Thursday to allow alternative health plans that skirt the law’s requirements.

The White House confirmed late Thursday that it would halt federal payments for cost-sharing reductions, although a statement did not specify when. Another statement a short time later by top officials at the Health and Human Services Department said the cutoff would be immediate. The subsidies total about $7 billion this year.

Trump has threatened for months to stop the payments, which go to insurers that are required by the laws to help eligible consumers afford their deductibles and other out-of-pocket expenses. But he held off while other administration officials warned him such a move would cause an implosion of the ACA marketplaces that could be blamed on Republicans, according to two individuals briefed on the decision.

Health insurers and state regulators have been in a state of high anxiety over the prospect of the marketplaces cratering because of such White House action. The fifth year’s open-enrollment season for consumers to buy coverage through ACA exchanges will start in less than three weeks, and insurers have said that stopping the cost-sharing payments would be the single greatest step the Trump administration could take to damage the marketplaces — and the law.

Ending the payments is grounds for any insurer to back out of its federal contract to sell health plans for 2018. Some states’ regulators directed ACA insurers to add a surcharge in case the payments were not made, but insurers elsewhere could be left in a position in which they still must give consumers the discounts but will not be reimbursed.

A spokeswoman for America’s Health Insurance Plans, an industry trade group that has been warning for months of adverse effects if the payments ended, immediately denounced the president’s decision. “Millions of Americans rely on these benefits to afford their coverage and care,” Kristine Grow said.

And California Attorney General Xavier Becerra (D), who has been trying to preserve the payments through litigation, said the president’s action “would be sabotage.” Becerra said late Thursday that he was prepared to fight the White House. “We’ve taken the Trump Administration to court before and won, and we’re ready to do it again if necessary,” he said in a statement.

Trump’s move comes even as bipartisan negotiations continue on one Senate Committee over ways to prop up the ACA marketplaces. Both Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) have publicly said the payments should not end immediately, though they differ over how long these subsidies should be guaranteed.

The cost-sharing reductions — or CSRs, as they are known — have long been the subject of a political and legal seesaw. Congressional Republicans argued that the sprawling 2010 health-care law that established them does not include specific language providing appropriations to cover the government’s cost. House Republicans sued HHS over the payments during President Barack Obama’s second term. A federal court agreed that they were illegal, and the case has been pending before the U.S. Court of Appeals for the D.C. Circuit.

“The bailout of insurance companies through these unlawful payments is yet another example of how the previous administration abused taxpayer dollars and skirted the law to prop up a broken system,” a statement from the White House said. “Congress needs to repeal and replace the disastrous Obamacare law and provide real relief to the American people.”

House Speaker Paul D. Ryan (R-Wis.) said in a statement that the administration was dropping its appeal of the lawsuit — something the White House did not mention in its announcement. Ryan called the move to end to the court case “a monumental affirmation of Congress’s authority and the separation of powers.”

Meanwhile, the top two congressional Democrats, House Minority Leader Nancy Pelosi (Calif.) and Senate Minority Leader Charles E. Schumer (N.Y.), excoriated the president’s decision. “It is a spiteful act of vast, pointless sabotage leveled at working families and the middle class in every corner of America,” they said in a joint statement. “Make no mistake about it, Trump will try to blame the Affordable Care Act, but this will fall on his back and he will pay the price for it.

For months, administration officials have debated privately about what to do. The president has consistently pushed to stop the payments, according to officials and advisers who spoke on the condition of anonymity to discuss private conversations. Some top health officials within the administration, including former HHS secretary Tom Price, cautioned that this could exacerbate already escalating ACA plan premiums, these Republicans said. But some government lawyers argued that the payments were not authorized under the existing law, according to one administration official, and would be difficult to keep defending in court.

Acting HHS Secretary Eric Hargan and Seema Verma, administrator of the department’s Centers for Medicare and Medicaid Services, said they were stopping the payments based on a legal opinion by Attorney General Jeff Sessions. “It has been clear for many years that Obamacare is bad policy. It is also bad law,” their statement says. “The Obama Administration unfortunately went ahead and made CSR payments to insurance companies after requesting — but never ultimately receiving — an appropriation from Congress as required by law.”

While the administration will now argue that Congress should appropriate the funds if it wants them to continue, such a proposal will face a serious hurdle on Capitol Hill. In a recent interview, Rep. Tom Cole (R-Okla.), who chairs the House Appropriations Subcommittee overseeing HHS, said it would be difficult to muster support for such a move among House conservatives.

One person familiar with the president’s decision said that HHS officials and Trump’s domestic policy advisers had urged him to continue the payments at least through the end of the year.

The cost-sharing payments are separate from a different subsidy that provides federal assistance with premiums to more than four-fifths of the 10 million Americans with ACA coverage.

Word of the president’s decision came just hours after he signed the executive order intended to circumvent the ACA by making it easier for individuals and small businesses to buy alternative types of health insurance with lower prices, fewer benefits and weaker government protections.

The White House and allies portrayed the president’s move as wielding administrative powers to accomplish what congressional Republicans have failed to achieve: fostering more coverage choices while tearing down the law’s insurance marketplaces. Until the White House’s announcement late Thursday, the executive order represented Trump’s biggest step to date to reverse the health-care policies of the Obama administration, a central promise since last year’s presidential campaign.

Critics, who include state insurance commissioners, most of the health-insurance industry and mainstream policy specialists, predict that a proliferation of these other kinds of coverage will have damaging ripple effects, driving up costs for consumers with serious medical conditions and prompting more insurers to flee the law’s marketplaces. Part of Trump’s action, they say, will spark court challenges over its legality.

The most far-reaching element of the order instructs a trio of Cabinet departments to rewrite federal rules for “association health plans” — a form of insurance in which small businesses of a similar type band together through an association to negotiate health benefits. These plans have had to meet coverage requirements and consumer protections under the 2010 health-care law, but the administration is likely to exempt them from those rules and let such plans be sold from state to state without insurance licenses in each one.

In addition, the order is designed to expand the availability of short-term insurance policies, which offer limited benefits as a bridge for people between jobs or young adults no longer eligible for their parents’ health plans. The Obama administration ruled that short-term insurance may not last for more than three months; Trump wants to extend that to nearly a year.

Trump’s action also is intended to widen employers’ ability to use pretax dollars in “health re­imbursement arrangements” to help workers pay for any medical expenses, not just for health policies that meet ACA rules — another reversal of Obama policy.

In a late-morning signing ceremony in the White House’s Roosevelt Room, surrounded by supportive small-business owners, Cabinet members and a few Republicans from Capitol Hill, the president spoke in his characteristic superlatives about the effects of his action and what he called “the Obamacare nightmare.”

Trump said that Thursday’s move, which will trigger months of regulatory work by federal agencies, “is only the beginning.” He promised “even more relief and more freedom” from ACA rules. And although leading GOP lawmakers are eager to move on from their unsuccessful attempts this year to abolish central facets of the 2010 law, Trump said that “we are going to pressure Congress very strongly to finish the repeal and replace of Obamacare.”

The executive order will fulfill a quest by conservative Republican lawmakers, especially in the House, who have tried for more than two decades to expand the availability of association health plans by allowing them to be sold, unregulated, across state lines. On the other hand, Trump’s approach conflicts with what he and GOP leaders in Congress have held out as a main health-policy goal — giving each state more discretion over matters of insurance.

Health policy experts in think tanks, academia and the health-care industry pointed out that the order’s language is fairly broad, so the ensuing fine print in agencies’ rules will determine whether the impact will be as sweeping or quick as Trump boasted — his directive will provide “millions of people with Obamacare relief,” he said.

Significant questions that remain include whether individuals will be able to join associations, a point that could raise legal issues; whether the administration will start to let association health plans count toward the ACA’s requirement that most Americans carry insurance; and whether such plans can charge higher prices to small businesses with sicker workers — or refuse to insure them.

A senior administration official, speaking to reporters on the condition of anonymity shortly before Trump signed the order, said that the policy changes it sets in motion will require agencies to follow customary procedures to write new rules and solicit public comment. That means new insurance options will not be available in time for coverage beginning in January, he said.

Among policy experts, critics warned that young and healthy people who use relatively little insurance will gravitate to association health plans because of their lower price tags. That would concentrate older and sicker customers in ACA marketplaces with spiking rates.

Selling health plans from state to state without separate licenses — the idea underlying much of the president’s order — has long been a Republican mantra. It has gained little traction in practice, however.

Half a dozen states — before the ACA was passed in 2010 as well as since then — have passed laws permitting insurers to sell health policies approved by other states. And since last year, the ACA has allowed “compacts” in which groups of states can agree that health plans licensed in any of them could be sold in the others. Under such compacts, federal health officials must make sure the plans offer at least the same benefits and are as affordable as those sold in the ACA marketplaces.

As of this summer, “no state was known to actually offer or sell such policies,” according to a report by the National Conference of State Legislatures. A main reason, experts say, is insurers’ difficulty in arranging networks of doctors and other providers of care far from their home states.


GOP odds rise on ObamaCare repeal



The Trump administration and Republican leaders in Congress are going all-in on a last-ditch effort to replace ObamaCare.

Earlier this month, the GOP effort was all but dead as Republican leaders pivoted to tax reform. But the health-care legislation has picked up a significant amount of momentum over the past several days.

“I’ve never felt better about where we’re at,” Sen. Lindsey Graham (R-S.C.), one of the bill’s sponsors, told reporters after senators met with Vice President Pence to discuss the new health-care proposal.

“At the end of the day, I really believe we’re going to get 50 Republican votes,” he added.

Other GOP senators said the measure has a real prospect of success.

“Our members are thinking about it, they’re studying it. They’re talking to the authors of the bill. But I think we’ve made good headway,” said Senate Republican Conference Chairman John Thune (S.D.).

The unexpected second wind for the ObamaCare repeal effort has been helped greatly by the deal President Trump struck with Democrats earlier this month to fund hurricane relief and postpone a battle over federal spending and the debt limit until December.

Republicans at the time panned Trump for cutting GOP leaders out of the loop, but now his decision looks like a master stroke as it has created time on the schedule to take a second shot at health-care reform.

The upcoming deadline of Sept. 30 has also played a leading role in the rising prospects of the legislation. If an ObamaCare replacement bill isn’t signed into law by then under budget reconciliation rules, it would need 60 votes to pass.

Under the special rules, 50 votes plus a tie-breaker from Pence would send it to the House, where leading Republicans have indicated they would pass it and send it to Trump’s desk before the end of the month.

The newest legislative effort, named after co-sponsors Graham and Sen. Bill Cassidy (R-La.), a physician, would largely dismantle ObamaCare and convert its funding to block grants to states, empowering them to design new programs.

Democrats warn the block grants would be too small and would lead to cuts in Medicaid and other health-care spending.

The bill would also allow states to waive ObamaCare rules, including the prohibition on people with pre-existing conditions being charged higher premiums.

Pence and Senate Majority Leader Mitch McConnell (R-Ky.) told GOP lawmakers at Tuesday’s meeting that this is their last chance to fulfill their promise to repeal ObamaCare.

Sen. Ron Johnson (R-Wis.), another one of the bill’s sponsors, described Pence’s message as “really strong.”

McConnell warned colleagues that “if we do nothing, ObamaCare continues” and “this is the last best chance for putting ourselves back on a path where states get greater control,” according to Johnson.

Pence and Graham discussed how to whip up support for the bill aboard Air Force Two Tuesday during a flight back to Washington from New York, where they watched Trump’s first address to the United Nations.

Pence told a pool reporter on the flight that the president and the entire administration strongly back the new measure and have called senators and governors to build political support.

Trump phoned Graham, a former rival in the 2016 presidential race, late Monday evening to encourage him and promise his backing.

Pence said ahead of the lunch that he would press wavering senators.

“This is the moment. Now is the time. We have 12 days,” he said, according to the pool report.

GOP leaders have no margin for error.

Conservative Sen. Rand Paul (R-Ky.) has already announced he will oppose the legislation because it does not fully repeal ObamaCare, and Sen. Susan Collins (R-Maine) — who is considering a run for governor — has signaled she is also a likely no. Paul backed the prior Senate health-care measure while Collins rejected the bill, which was defeated by one vote.

Collins has expressed concern that the Congressional Budget Office (CBO) will not be able to deliver a full analysis of the legislation before a possible vote next week and said Tuesday she did not receive any new information after meeting with Pence.

She has introduced her own bipartisan proposal with Sen. Bill Nelson (D-Fla.) that would help states create reinsurance programs for their insurance markets to lower health-care premiums.

The Senate Finance Committee is scheduled to hold a hearing on the legislation Monday and a truncated analysis is expected from the CBO early next week.

The non-partisan budget office has indicated it would take several weeks to draft a full report with projections on premium costs and the number of uninsured.

At least four other Republicans are undecided, including Sens. John McCain (Ariz.) and Lisa Murkowski (Alaska). Both voted to kill the pared-down ObamaCare repeal bill before the August recess.

Sens. Dan Sullivan (R-Alaska) and Shelley Moore Capito (R-W.Va.) said they are also undecided about the legislation, which would deliver big cuts in federal aid to their home states.

The effort suffered a setback Tuesday when several key governors — most importantly Alaska Gov. Bill Walker (I) — released a letter expressing opposition.

“We ask you not to consider the Graham-Cassidy-Heller-Johnson amendment and renew support for bipartisan efforts to make health care more available and affordable for all Americans,” Walker wrote, along with other governors, including John Kasich of Ohio and Brian Sandoval of Nevada. “Only open, bipartisan approaches can achieve true, lasting reforms.”

Murkowski said she is in close consultation with Walker.

Sen. Dean Heller (Nev.), who is the most vulnerable Republican senator facing reelection next year, was a swing vote during the health-care debate earlier this summer, but he is a co-sponsor of Graham-Cassidy.

The governors instead praised a bipartisan effort at an ObamaCare stabilization measure that had been under negotiation in the Senate Health Committee.

Pence on Tuesday, however, slammed the door on the alternative possibility of moving legislation to shore up the individual insurance markets, noting that Speaker Paul Ryan (R-Wis.) has pledged it doesn’t have enough votes to pass the House.

Pence and Ryan spoke by phone during Pence’s return flight to Washington.

Ryan has also told McConnell that a stabilization bill from the Senate Health Committee “isn’t viable” in the House, according to a source familiar with the discussion.

Sen. Lamar Alexander (R-Tenn.), who had been leading the talks on a stabilization bill, declared the effort over Tuesday.

Republicans are increasingly pointing to their latest ObamaCare repeal bill as the only option to avoid the single payer proposal championed by Sen. Bernie Sanders (I-Vt.) and 16 of his Democratic colleagues.

“Here’s the choice for America: socialism or federalism when it comes to your health care,” Graham told reporters after the lunch meeting.

Graham says the bill he’s co-sponsored would redistribute money now disproportionately being spent in four Democratic states — New York, California, Massachusetts and Maryland — to the rest of the country.

Sen. Dianne Feinstein (D-Calif.) accused Graham and Cassidy of unfairly targeting her state.

“It’s appalling that Senator Graham and Senate Republicans would take federal funds that provide health care to Californians to give them to Republican-leaning states,” she said in a statement.

Health Care Debate: Obamacare Repeal Fails as McCain Casts Decisive No Vote

• The Senate rejected legislation to repeal parts of the Affordable Care Act, with Senator John McCain casting a decisive “no.”

• Senate Republicans unveiled a “skinny repeal,” a narrow measure to roll back parts of the Affordable Care Act. It would leave 15 million more Americans without insurance next year, the Congressional Budget Office said.

• Speaker Ryan tried to reassure senators balking at the narrow bill, but he left the door open for “skinny” passage.

Republicans 49 3
Democrats 0 48
Total 49 51

Senate rejects scaled-down Obamacare repeal.

The Senate on Friday rejected a new, scaled-down Republican plan to repeal parts of the Affordable Care Act, seemingly derailing the Republicans’ seven-year campaign to dismantle the health care law.

Senator John McCain, Republican of Arizona, cast a decisive vote to defeat the proposal, joining two other Republicans, Susan Collins of Maine and Lisa Murkowski of Alaska, in opposing it.

The 49-51 vote was a huge setback for the majority leader, Mitch McConnellof Kentucky, who has spent the last three months trying to devise a repeal bill that could win support from members of his conference. It was also a blow to President Trump, who lashed out.

The truncated Republican plan was far less than what Republicans once envisioned. Republican leaders, unable to overcome complaints from both moderate and conservative members of their caucus, said the skeletal plan was just a vehicle to permit negotiations with the House, which passed a much more ambitious repeal bill in early May.

The so-called “skinny” repeal bill, as it became known at the Capitol this week, would still have broad effects on health care. The bill would increase the number of people who are uninsured by 15 million next year compared with current law, according to the nonpartisan Congressional Budget Office. Premiums for people buying insurance on their own would increase by roughly 20 percent, the budget office said.

But President Trump backed it to the hilt, pressuring, cajoling and threatening wavering Republicans.

Shortly before the vote, he took to Twitter.

McConnell unveils narrow Obamacare repeal bill.

Senator Mitch McConnell, the majority leader, pulled in his sails on repealing the Affordable Care Act, and unveiled a more narrow measure that would:

REPEAL THE INDIVIDUAL MANDATE, which says that most Americans must have health insurance or pay a tax penalty.

REPEAL THE EMPLOYER MANDATE, which requires large employers to offer health insurance to their workers.

GIVE FLEXIBILITY TO STATES, making it much easier for them to waive federal requirements that health plans provide consumers with a minimum set of benefits like maternity care and prescription drugs.

EXPAND HEALTH SAVINGS ACCOUNTS, increasing the limit on contributions to such tax-favored accounts



Read the Senate
‘Skinny Repeal’ Bill

Republicans on Thursday released a narrow measure to roll back parts of the Affordable Care Act.


C.B.O.: ‘Skinny’ bill would leave 15 million more uninsured.

The Congressional Budget Office said the latest, more narrow bill to dismantle the Affordable Care Act would leave 15 million more Americans without insurance next year and would raise insurance premiums by about 20 percent over the next decade.

The measure would decrease federal budget deficits by about $179 billion over a decade, according to the budget office.

Ryan tried to calm Senate nerves.

With senators pleading for reassurance, Speaker Paul D. Ryan did his best.

“If moving forward requires a conference committee, that’s something the House is willing to do. The reality, however, is that repealing and replacing Obamacare still ultimately requires the Senate to produce 51 votes for an actual plan.”

He then said whatever compromise comes out of the House-Senate conference would have to pass the Senate first before the House picks it up.

That was not all that reassuring. If the Senate failed to pass that conference agreement, the House could have still passed the Senate’s “skinny repeal” and sent it to President Trump for the signing ceremony he desperately wants.

That was decisive for Mr. McCain.

“Creepy Billionaires.”

That’s who Senator Sheldon Whitehouse, Democrat of Rhode Island, said were dictating the terms of the latest Republican health care bill. It does have a ring to it — could be a rock band.

Three Republicans: No ‘yes’ votes without assurances of a conference.

Senators Lindsey Graham of South Carolina, John McCain of Arizona and Ron Johnson of Wisconsin declared Thursday evening that they would not vote for a slimmed-down partial repeal of the Affordable Care Act that is being pushed by Senate leaders without ironclad guarantees that the House will negotiate a comprehensive measure.

The senators were unsparing in their criticism of the so-called skinny repeal, which would repeal the mandates that most individuals have health insurance and large employers cover their employees but leave most of the health law in place. Such a bill would crater the health insurance market and send premiums skyward, they said.

“The skinny bill as policy is a disaster,” Mr. Graham said. “The skinny bill as a replacement for Obamacare is a fraud.”


How Many People
Across America Are
at Risk of Losing Their
Health Insurance?

A state-by-state look at who could lose insurance under the proposed Republican health care plans.

Senator Johnson said: “The skinny bill in the Senate doesn’t come close to meeting our promises.”

But they feared that House Republican leaders could just take the stripped-down bill, pass it and send it to President Trump.

“Right now, I am voting no,” Mr. McCain said.

Mr. Graham was emphatic.

“I need assurances from the speaker of the House and his team that if I vote for the skinny bill, then it will not be the final product,” Mr. Graham said. “I’m not going to vote for a pig in a poke.”

From left, Senators Lindsay Graham of South Carolina, John McCain of Arizona and Ron Johnson of Wisconsin, all Republicans, spoke about the “skinny repeal” bill on Thursday. CreditJustin Gilliland/The New York Times

Mr. Ryan’s assurances may just win the night. For all his bluster, Mr. Graham said he would trust the speaker.

Sen. Johnson also looked like a yes.

But Mr. McCain was holding out.

Senate Republicans trim sails on ‘Repeal and Replace.’

The turmoil came as Senate Republicans, unable to reach consensus on broad legislation to repeal and replace the Affordable Care Act, looked instead at chipping away at it.

Besides the mandates, Senator David Perdue, Republican of Georgia, said the other item under discussion for the so-called Skinny Repeal is rolling back a tax on medical devices imposed by the health law.

But to avoid a 60-vote threshold for passage, the bill must meet specific deficit reduction targets. It’s still not clear how those targets will be reached.

Then there’s the question of what would come next. Republican leaders are assuring senators that the narrow repeal would be merely a vehicle to begin negotiations with House Republicans on a broader compromise to repeal and replace the Affordable Care Act. But some senators worry that they are being asked to vote for legislation they don’t like on a promise that it won’t become law — but they have no guarantee that the House won’t take it up and pass it.

This might not have helped.

As Republican senators seek assurances that the bill they are being asked to vote on won’t become law, the House majority leader, Kevin McCarthy of California, may have sent shivers down a spine or two in the upper chamber with this announcement.

“While last votes are currently scheduled to take place tomorrow, Members are advised that — pending Senate action on health care — the House schedule is subject to change. All Members should remain flexible in their travel plans over the next few days. Further information regarding potential additional items will be relayed as soon as possible.”

That doesn’t sound like a man preparing for lengthy House-Senate negotiations on a comprehensive health care bill. So maybe the “skinny repeal” could become law after all?

Parliamentarian takes another scalp.

Senate Republicans also would have liked the “skinny repeal” to include a measure that would make it much easier for states to waive federal requirements that health insurance plans provide consumers with a minimum set of benefits like maternity care and prescription drugs.

Then the Senate parliamentarian stepped in. The parliamentarian, Elizabeth MacDonough, objected on Thursday to the waiver provision, saying it appeared to violate Senate rules being used to speed passage of the bill to repeal much of the Affordable Care Act.

Republicans want to make it easier for states to get waivers for two reasons: State officials can regulate insurance better than federal officials, they say, and the federal standards established by the Affordable Care Act have driven up insurance costs.

But Republicans are learning the limits of the fast-track rules they are using. The Senate is considering the repeal bill under special procedures that preclude a Democratic filibuster, but the procedures also limit what can be included in the bill.

“The function of reconciliation is to adjust federal spending and revenue, not to enact major changes in social policy,” said Senator Bernie Sanders, independent of Vermont. “The parliamentarian’s latest decision reveals once again that Republicans have abused the reconciliation process in an attempt to radically change one-sixth of the American economy by repealing the Affordable Care Act.”

The Senate bill would give states sweeping new authority to opt out of federal insurance standards established by the Affordable Care Act. It builds on a section of the law that allows states to obtain waivers for innovative health programs. But it would relax many of the requirements for such waivers that Democrats put into the law, signed by President Barack Obama in 2010.

Insurers come off sidelines with warning.

The health insurance lobby, America’s Health Insurance Plans, came off the sidelines on Thursday to warn Senate leaders against repealing the Affordable Care Act’s mandate that most Americans have insurance without approving some mechanism to pressure people to maintain their coverage.

“We would oppose an approach that eliminates the individual coverage requirement, does not offer continuous coverage solutions, and does not include measures to immediately stabilize the individual market,” the group wrote.

AHIP played a major role in getting the Affordable Care Act passed in 2010 but has been reluctant to intervene in the fight over its repeal. On Wednesday, the Blue Cross Blue Shield Association, a narrower insurance lobby, weighed in with a similar warning.

Both groups were pulled into the fray by expectations that the Senate could end up voting in the early morning hours of Friday on a narrow bill that repeals a few important parts of the Affordable Care Act but leaves much of the law in place. Two of the pieces that would be repealed are the mandates that individuals have health insurance and that large employers cover their employees. The Senate had intended to repeal those mandates but create a new rule that anyone who allows coverage to lapse would have to wait six months before getting a new policy.

That lock out period was supposed to be enough to convince people not to simply wait until they were sick to buy insurance, a prospect that could send insurance markets into a tailspin, since only sick people would have insurance.

But it looks certain that any bill that can emerge from the Senate would not have the lock out provision, a deep concern to insurers who say that without it, insurance premiums would soar.

The American Medical Association piles on.

The American Medical Association, by far the largest physicians’ advocacy group, has stood firmly against each of the bills to repeal the Affordable Care Act. Now the A.M.A. has come out against the “skinny repeal.”

“There has been considerable speculation regarding a so-called ‘skinny package’ that would primarily eliminate penalties related to the individual and employer mandates and provide tax cuts to device manufactures and the health insurance industry. Eliminating the mandate to obtain coverage only exacerbates the affordability problem that critics say they want to address. Instead, it leads to adverse selection that would increase premiums and destabilize the individual market.

“We again urge the Senate to engage in a bipartisan process – through regular order – to address the shortcomings of the Affordable Care Act and achieve the goal of providing access to quality, affordable health care coverage to more Americans.”

Oh, and so does AARP.

Protesters make their voices known.

Capitol Police officers stopped a group of protesters on Thursday. CreditTom Brenner/The New York Times

Across the Capitol on Thursday, supporters of the Affordable Care Act tried to reach out to senators, sometimes through mass protests, sometimes through their stories.

“I had epilepsy as a kid. I would not have been able to be covered under what you’re proposing,” one man told Senator Richard Shelby, Republican of Alabama.

The senator replied: “I think we need to have — not just for you but for any group that is underserved medically — we ought to protect them.”

Vigils broke out throughout the Capitol and around lawmakers’ offices.

Protesters in the Senate gallery chanting “kill the bill” disrupted proceedings on Tuesday just before the Senate voted, 51-50, to begin the health care debate. Democrats, including Senator Cory Booker of New Jersey, spoke to crowds on the steps of the building. Hundreds of protesters flooded the lawns outside the Capitol.

“The message was: we are not backing down,” Nora Franco, campaign organizer at Planned Parenthood, said in the Capitol. She added, “Now is not the time to throw in the towel. Now is the time to literally be harassing your senators.”

Seven years ago, similar scenes unfolded before the votes on the Affordable Care Act, but then, the passion came from the opponents. Those voices now are little in evidence.

Has Alaska’s delegation crossed Trump?

President Trump went after Senator Lisa Murkowski of Alaska, who was one of only two Republicans to vote against starting debate on health care this week, with a Twitter post on Wednesday.

But that might not be the end of it.

Ryan Zinke, the Interior secretary, called both Ms. Murkowski and Alaska’s other senator, Dan Sullivan, “letting them know the vote had put Alaska’s future with the administration in jeopardy,” The Alaska Dispatch News reported. Mr. Sullivan, also a Republican, voted in favor of beginning debate.

“I’m not going to go into the details, but I fear that the strong economic growth, pro-energy, pro-mining, pro-jobs and personnel from Alaska who are part of those policies are going to stop,” Mr. Sullivan said, according to the newspaper.

But the leverage goes both ways.

Ms. Murkowski is the chairwoman of the Senate Energy and Natural Resources Committee, which has oversight of the Interior Department. She is also the chairwoman of the Senate Appropriations subcommittee with jurisdiction over the department.

She likely can do more to Mr. Zinke than he can do to her.

Tracked down by reporters on Capitol Hill, Mr. Sullivan called for the administration and Alaska’s small but powerful congressional delegation to “get back to cooperation.”

No word yet from Ms. Murkowski.

Where did the Senate leave off on Wednesday?

Wednesday’s big vote was on a measure to repeal major parts of the existing health law — but without swapping in something new.

Republicans have struggled to agree on the contents of a replacement for the law, so a “clean repeal” bill seemed like a good alternative to some of them.

But the measure was soundly rejected. Seven Republicans — including Senator Lamar Alexander of Tennessee, the chairman of the Senate health committee — joined Democrats in voting against it.

The repeal-only measure was expected to fail. But the episode demonstrated the problem facing Republican leaders: They don’t have enough votes to pass a broad replacement of the health law. They also don’t have the votes to simply repeal major parts of it.

What happens on Thursday?

Senate Republicans have been trying to push through a repeal by using special budget rules that limit debate to 20 hours. That time is expected to be exhausted on Thursday.

After it expires, the Senate will move into what is known as a “vote-a-rama”— a marathon series of votes on amendments.

Senator Chuck Schumer, the minority leader, leaving the Senate chamber after lawmakers on Wednesday rejected a proposal to repeal the health care law. CreditStephen Crowley/The New York Times

Typically, Democrats would be expected to offer a barrage of amendments. But on Wednesday night, the minority leader, Chuck Schumer of New York, said Democrats would not offer any amendments until Mr. McConnell revealed the final bill he wants the Senate to consider.

“We ought to see it soon, in broad daylight, not at the 11th hour,” Mr. Schumer said.

The vote-a-rama could begin late in the day on Thursday. If Democrats do offer a blizzard of amendments, it could stretch overnight. But it remains unclear when, exactly, Mr. McConnell plans to reveal his legislation.

Republicans seem increasingly likely to try to pass a slimmed-down bill that would repeal only a small number of the existing health law’s provisions. By passing a so-called “skinny” repeal bill, Senate Republicans would keep the repeal effort alive long enough to try to negotiate a broader compromise bill with the House of Representatives.

Senate Votes Down Broad Obamacare Repeal

WASHINGTON — The Senate voted narrowly on Tuesday to begin debate on a bill to repeal major provisions of the Affordable Care Act, but hours later, Republican leaders suffered a setback when their most comprehensive plan to replace President Barack Obama’s health law fell far short of the votes it needed.

The Tuesday night tally needed to reach 60 votes to overcome a parliamentary objection. Instead, it fell 43-57. The fact that the comprehensive replacement plan came up well short of even 50 votes was an ominous sign for Republican leaders still grappling with a formula to pass final health care legislation this week.

For Republicans, the failure ended the day on a sour note, hours after a more triumphant scene in the well of the Senate. Lawmakers from both parties had risen to their feet in the afternoon and applauded when Senator John McCain, Republican of Arizona, showed up in the chamber despite his diagnosis of brain cancer. He cast a crucial vote in favor of opening what promises to be a freewheeling, hard-fought debate over the future of the Affordable Care Act.

The 51-50 vote to start debate, with Vice President Mike Pence breaking a tie, came only a week after the Republican effort to dismantle a pillar of former President Barack Obama’s legacy appeared all but doomed. It provided an initial win for President Trump, who pushed, cajoled and threatened senators in recent days to at least begin debating the repeal of the health care law.

But the victory could be fleeting: Senate Republicans still have no agreement on a repeal bill that they can ultimately pass to uproot the law that has provided health insurance to millions of Americans.

The Senate is now moving ahead with debate, amendments and ultimately a final vote in the coming days on legislation that would have a profound effect on the American health care system — roughly one-sixth of the United States’ economy. But it is entirely possible that by week’s end, they will have passed nothing.

“Now we move forward towards truly great health care for the American people,” Mr. Trump said from the White House Rose Garden, where he was holding a news conference with the visiting prime minister of Lebanon. “This was a big step.”

Only two Republicans, Susan Collins of Maine and Lisa Murkowski of Alaska, voted against the procedural motion, though at least several other Republicans had been seen as possible holdouts. No Democrats voted in favor of the motion.

The Tuesday night vote was on a comprehensive amendment that included disparate proposals calculated to appeal to conservatives and moderates in the Republican caucus.

One proposal, offered by Senator Ted Cruz, Republican of Texas, would have allowed insurers to sell stripped-down health plans, without maternity care or other benefits required by the Affordable Care Act, if they also sold plans that included such benefits.

“You shouldn’t have to buy what the federal government mandates you must buy,” Mr. Cruz said. “You should choose what meets the needs for you and your family.”

The amendment also included money to help pay out-of-pocket medical costs for certain low-income people, including those who buy private insurance after losing Medicaid coverage as a result of the Senate bill. This proposal was devised by Senator Rob Portman, Republican of Ohio, and other senators from states that have expanded Medicaid under the Affordable Care Act.

But nine Republicans defected from the package, but all ends of the party’s ideological spectrum.

The debate to come will have broad implications for health care and households in every state, and emotions are high.

Before senators voted to start the debate in midafternoon, protesters in the Senate gallery chanted, “Kill the bill, don’t kill us!” and “Shame, shame, shame!”

Despite his vote to move ahead, Mr. McCain offered harsh words for the secretive process by which Senate Republican leaders came up with their bill to repeal and replace the health law, and he delivered a pessimistic take on its chances.

“Asking us to swallow our doubts and force it past a unified opposition — I don’t think that’s going to work in the end, and probably shouldn’t,” Mr. McCain said, adding that it “seems likely” that the current repeal effort would end in failure.

Arizona is one of the 31 states that expanded Medicaid under the Affordable Care Act, and Mr. McCain’s remarks could be an ominous sign for other senators from states that expanded Medicaid, including the junior Republican senator from his state, Jeff Flake.

“We are ground zero for the failure of the exchanges, but we are also an expansion state,” Mr. Flake said. “I think all of us are concerned that we don’t pull the rug out from people.”

Just before the Senate vote, the Democratic leader, Chuck Schumer of New York, made an impassioned plea to Republicans.

“We know that A.C.A. is not perfect,” Mr. Schumer said. “But we also know what you’ve proposed is much worse. We can work together to improve health care in this country. Turn back now before it’s too late and millions and millions and millions of Americans are hurt so badly in ways from which they will never, ever recover.”

Majority needed to pass YES NO
Republicans 51 2
Democrats 0 48
Total 51 50

Given the divisions within their caucus, Senate Republican leaders were considering a new approach to keeping their repeal quest alive: They could try to reach agreement on a slimmed-down bill that would repeal a few major provisions of the Affordable Care Act, like the penalties imposed on people who go without insurance and businesses that do not offer insurance to their employees. Republicans leaders would not intend for such a bill to become law, but they believe that it could win approval in the Senate.

That “skinny” bill could then be a basis for negotiations with the House.

Republican leaders in Congress have struggled all year to fulfill their promise of repealing the 2010 health care law. By a vote of 217 to 213, the House approved a repeal bill in early May, but only after Republicans overcame their own difficulties in that chamber.

Mr. Trump kept up pressure on the Senate on Tuesday with Twitter posts. After the procedural vote, he applauded the Senate, but was cutting toward Ms. Collins and Ms. Murkowski: “We had two Republicans that went against us, which is very sad, I think. It’s very, very sad for them.”

The successful procedural vote was also a moment of redemption, at least temporarily, for Mr. McConnell, who just last week appeared to have failed in his effort to put together a health bill that could squeak through the narrowly divided Senate.

That said, it remained far from certain whether Republicans would be able to agree on a bill in the days to come — and what exactly the contents of that bill would be. Mr. McConnell promised an “open amendment process” in which members of both parties could propose changes.

“This is just the beginning,” Mr. McConnell said. “We’re not out here to spike the football.”

For weeks, Mr. McConnell has been promoting and revising a comprehensive bill that would repeal the health law while also replacing it, but he has struggled to nail down the support needed to pass that measure. The nonpartisan Congressional Budget Office has yet to assess the most complete version of that legislation, which includes the proposals by Mr. Cruz and Mr. Portman.

Without that assessment, the measure needed 60 Senate votes, and it failed that test on Tuesday night.

The Senate is also expected to vote on a measure that would repeal the health law without putting in place any replacement, but that approach does not appear to have enough support to pass, either.

That proposal resembles a bill passed by the Senate in 2015 and vetoed by Mr. Obama in early 2016. But it would increase the number of people who are uninsured by 32 million in 2026, the budget office said.

Senator Portman had anguished for weeks over provisions of Mr. McConnell’s repeal bill that would make deep cuts in projected Medicaid spending and roll back the expansion of the program under the Affordable Care Act.

Mr. Portman voted to move ahead with the debate on Tuesday after being assured that the Senate would vote on his plan to provide financial assistance to people moving from an expanded state Medicaid program to private health insurance.

States could have used the money, totaling $100 billion, to help low-income people pay deductibles and other out-of-pocket costs when they receive medical care.

Mr. Portman worked on the plan with the Trump administration and with several other Republican senators from several states that have expanded Medicaid, including Shelley Moore Capito of West Virginia and Dean Heller of Nevada.

Mr. Heller voted Tuesday to open the debate, but he made no commitment to vote for the repeal bill itself.

“If the final product isn’t improved for the state of Nevada, then I will not vote for it,” Mr. Heller said. “If it is improved, I will support it.”

Pence Breaks Tie as Senate Votes to Begin Debating Obamacare Repeal

WASHINGTON — The Senate narrowly voted on Tuesday to begin debate on a bill to repeal major provisions of the Affordable Care Act, taking a pivotal step forward after the dramatic return of Senator John McCain, who cast a crucial vote despite his diagnosis of brain cancer.

Vice President Mike Pence cast the tie-breaking vote.

The 51-50 vote came only a week after the Republican effort to dismantle a pillar of former President Barack Obama’s legacy appeared all but doomed. It marked an initial win for President Trump, who pushed, cajoled and threatened senators over the last days to at least begin debating the repeal of the health care law.

But even with that successful step, it is unclear whether Republicans will have the votes they need to uproot the law that has provided health insurance to millions of Americans. The Senate will now begin debating, amending and ultimately voting in the coming days on legislation that would have a profound impact on the American health care system.

Majority needed to pass YES NO
Republicans 51 2
Democrats 0 48
Total 51 50

By a single vote, the Senate cleared the way for an epic battle over the future of the health law. Only two Republicans, Susan Collins of Maine and Lisa Murkowski of Alaska, voted against the motion. The debate has broad implications for health care and households in every state.

Senate Republican leaders have struggled all year to fulfill their promise of repealing the 2010 health care law, and the procedural vote in the Senate on Tuesday risked being another big setback for the party. The House narrowly approved a repeal bill in early May, but only after Republicans overcame their own difficulties in that chamber.

President Trump kept up the pressure on Tuesday by posting on Twitter. “After 7 years of talking,” he said, “we will soon see whether or not Republicans are willing to step up to the plate!”

The successful procedural vote on Tuesday is an important step forward for the Senate majority leader, Mitch McConnell of Kentucky, who only a week ago appeared to have failed in his effort to put together a health bill that could squeak through the narrowly divided Senate.

That said, it remained far from certain whether Republicans would actually be able to agree on a bill in the days to come — and what exactly the contents of that bill would be.

For weeks, Mr. McConnell has been promoting and revising a comprehensive bill that would repeal the health law while also replacing it, but he has struggled to nail down the necessary support to pass that measure.

An alternative would be to pass a narrower bill that would repeal the health law without putting in place a replacement, but that approach has been greeted with objections from some Republicans as well.

What’s Next for Health Care if GOP Can’t Repeal Obamacare



WASHINGTON — After six months of twists and turns in Congress, Republican efforts to repeal Obamacare crashed on Tuesday as Senate Majority Leader Mitch McConnell conceded his party lacked the votes to pass a replacement.

But that’s not the end of the story. There are still significant problems in Obamacare’s exchanges to address and a looming political fight in the midterm elections next year. Here are some of the biggest questions going forward for both parties and the White House.

Does Trump blow up Obamacare on his own?

“I’m not going to own it,” President Donald Trump said on Tuesday after Republican plans to repeal Obamacare died. “I can tell you, the Republicans are not going to own it. We’ll let Obamacare fail and then the Democrats are gonna come to us.”

While Trump says he’ll “let” Obamacare fail, it’s more accurate to say he has the power to make Obamacare fail. That makes him the biggest player on health care in the immediate term.

Recent studies suggest that Obamacare’s markets are stabilizing after a bumpy year that saw premiums jump and insurers withdraw from many counties. The exchanges are still in fragile shape, however, and experts say Trump’s a major factor in the ongoing turmoil.

The president has threatened for months to withhold billions of dollars insurance companies are owed in “cost-sharing reduction” payments for reducing low-income customers’ deductibles. Insurers say they’re already raising 2018 premiums in response and are warning they may pull out of more counties — a handful of which currently have no individual insurers lined up for 2018 — if he cuts off the funding. They’re also worried Trump might refuse to enforce the individual mandate to buy insurance or to properly manage the next open enrollment period.

Trump could be treading on dangerous ground if he decides to sabotage Obamacare in order to pressure Democrats. A survey by the nonpartisan Kaiser Family Foundation in April found that 75 percent of respondents wanted Trump to try to make the law work versus 19 percent who said he should deliberately let it fail to encourage a replacement.

Can Republicans agree on a bipartisan bill?

McConnell said his party would talk to Democrats about small fixes to Obamacare if the GOP bill failed. But they could face another divisive internal debate about how far to go on a deal to smooth the insurance markets.

There are a number of Republicans, especially among the moderates, who say they’re open to a modest bipartisan bill that is something short of repeal. Even the relatively conservative Sen. Ron Johnson, R-Wisc., has suggested passing a short-term bill to bolster insurers.

“One of the major problems with Obamacare was that it was written on a strict party-line basis and driven through Congress without a single Republican vote,” Sen. John McCain, R-Ariz., said in a statement on Monday. He added that his party “must not repeat the original mistakes that led to Obamacare’s failure.”

In what could be interpreted as an olive branch to Democrats, the chair of the Health Education Labor and Pensions Committee, Sen. Lamar Alexander, R-Tenn., announced he would hold hearings on policies to stabilize the individual insurance market. Democrats had demanded throughout the process that Republicans hold public hearings with their input.

But not everyone’s so enthusiastic and Republicans will likely face pressure from their right flank not to put their stamp on Obamacare by voting for a bill that would help it succeed.

Senate Majority Whip Sen. John Cornyn, R-Texas, told reporters on Tuesday he was “not interested in bailouts for insurance companies alone without reforms” when asked about a possible stabilization bill and specifically dismissed the idea of guaranteeing cost-sharing reduction payments, the biggest demand among insurers.

Getting a vote in the House of Representatives could be even more difficult, where conservative groups have greater sway. House Speaker Paul Ryan told reporters he would not “foreclose any options” but was skeptical Democrats would be amenable to a deal.

Will Democrats come to the table?

Suddenly, Democrats are relevant again after being shunted aside for the entire health care process.

To hear their party’s Senate and House leaders tell it, they couldn’t be happier: Democrats lined up on Tuesday to say they were prepared to work with Republicans as long as they dropped demands to repeal Obamacare, cut Medicaid spending, or reduce taxes on the rich.

“The door to bipartisanship is open right now not with repeal, but with an effort to improve the existing system,” Senate Minority Leader Chuck Schumer, D-N.Y., said on Tuesday.

There are plenty of modest proposals out there already: Sen. Claire McCaskill, D-Mo., has a bill to let people in counties with no insurer buy plans from the same exchange members of Congress use. Democrats in the House and Senate have proposed reinsurance to help insurers cover expensive patients and suggested letting more customers buy cheap catastrophic plans.

“The Republicans have to understand that if they’re going to try to starve out the Affordable Care Act, they’re responsible for the outcome,” Sen. Dick Durbin, D-Ill., told NBC News. “We’d rather work with them to solidify this system.”

But Republicans are skeptical. Many say they don’t believe Democrats will settle for small tweaks and will inevitably demand bigger ticket items like a public option that activists are rallying behind.

“My strong suspicion is what our Democratic friends want is a single-payer system,” Sen. John Kennedy, R-La. told reporters.

Democratic senators insist there’s plenty of room for compromise. But with progressives making bolder and bolder demands on health care and increasingly animated by opposition to Trump, it remains to be seen how much negotiation their voters are willing to tolerate.

What happens to the House Republicans?

The Senate’s efforts to replace Obamacare may have died with a whimper, but House Republicans passed their bill, the American Health Care Act, with a bang in May that included a Rose Garden celebration with President Trump.

Polls showed AHCA was unpopular, however, and the bill was hampered by a subsequent CBO report finding it would insure 23 million fewer people, render insurance unaffordable for many people with pre-existing conditions, and cause huge spikes in premiums for older low-income Americans.

House members raised concerns about various policy items before their vote, but expected that the Senate would send them a better version that resolved their problems. Instead, the 217 members who backed AHCA are stuck with an orphaned bill that even Trump called “mean.

Charlie Dent,Ted Yoho
Rep. Charlie Dent, R-Pa., a key moderate in the health care bill debate, speaks on Capitol Hill on March 23. J. Scott Applewhite / AP file

“I had policy reasons for opposing the health care bill coming out of the House, but I also saw the political realities that the House health care bill had absolutely zero chance of passing the Senate,” Rep. Charlie Dent, R-Penn., a moderate Republican who voted against the bill, told NBC News.

If anyone knows the danger of passing a bill that goes nowhere, it’s Democrats: In 2010, Republicans pounded House members for passing a sweeping climate bill that died in the Senate. Now Democrats are eager to turn the tables.

“Paul Ryan can’t turn back time and undo the damaging vote he imposed on his conference,” Democratic Congressional Campaign Committee spokeswoman Meredith Kelly said in a statement on Tuesday.

Republican strategist Michael Steel, who served as press secretary to Speaker John Boehner, suggested things might not be so dire: If Republicans can rally behind a successful tax reform or infrastructure bill, the public could move on from the health care fight.

“I actually think the House Members may be in a better spot if the Senate fails to act,” Steel said. “They have kept their promise to repeal Obamacare, but can’t be blamed for unpopular future problems in the health care system.”

‘Plan C’ on Obamacare, Repeal Now, Replace Later, Has Collapsed

WASHINGTON — With their bill to repeal and replace the Affordable Care Act in tatters, Senate leaders on Tuesday pushed to vote on a different measure that would repeal major parts of President Barack Obama’s health law without a replacement — but that plan appeared also to collapse.

Senators Susan Collins of Maine, Shelley Moore Capito of West Virginia and Lisa Murkowski of Alaska, all Republicans, immediately declared they could not vote to repeal the Affordable Care Act without a replacement — enough to doom the effort before it could get any momentum.

“I did not come to Washington to hurt people,” Ms. Capito said in a statement. “I cannot vote to repeal Obamacare without a replacement plan that addresses my concerns and the needs of West Virginians.”

Senator Rob Portman of Ohio hinted strongly that he too would oppose it.

The collapse of the Senate Republican health bill — and the failing struggle to find yet another alternative — highlighted a harsh reality for Senate Republicans: While Republican senators freely assailed the health law while Mr. Obama occupied the White House, they have so far not been able to come up with a workable plan to unwind it that would keep both moderate Republicans and conservatives on board.

By midday Tuesday, the Republican Party’s seven-year-old promise to repeal the Affordable Care Act appeared broken. At the White House, President Trump said his plan was now “to let Obamacare fail,” suggesting Democrats would then seek out Republicans to work together on a health measure.

“It will be a lot easier,” Mr. Trump said, adding, “We’re not going to own it. I’m not going to own it. I can tell you the Republicans are not going to own it. We’ll let Obamacare fail and then the Democrats are going to come to us.”

Senator Mitch McConnell of Kentucky, the majority leader, gamely pressed forward on Tuesday even as the ground was giving way beneath him.

“I regret that the effort to repeal and immediately replace the failures of Obamacare will not be successful,” Mr. McConnell said on the Senate floor on Tuesday morning. “That doesn’t mean we should give up. We will now try a different way to bring the American people relief from Obamacare. I think we owe them at least that much.”

On Capitol Hill, Republicans and Democrats alike were trying to make sense of the bill’s downfall — and what comes next. On Monday night, two Republican senators, Mike Lee of Utah and Jerry Moran of Kansas, came out in opposition to the bill, leaving Republican leaders at least two votes short of those needed to start debate on the measure.

Two other Republican senators, Ms. Collins and Rand Paul of Kentucky, affirmed their opposition to the measure last week, leaving Mr. McConnell with no room for error as he tried to move toward a vote.

Speaking on the Senate floor on Tuesday morning, Mr. McConnell laid out plans for a vote on a measure like the one vetoed by Mr. Obama in January 2016, which, Mr. McConnell said, would include a “repeal of Obamacare combined with a stable, two-year transition period.”

Under that bill, the Congressional Budget Office said, 18 million more people would be uninsured within a year, and 32 million fewer people would have coverage in 2026, compared with current law. Premiums, it said, would increase at least 20 percent in the first year and would double by 2026.

That bill would have eliminated the Affordable Care Act’s expansion of Medicaid and subsidies for the purchase of private insurance. But it would have left in place rules established by the Affordable Care Act that require insurers to provide specific benefits and prohibit insurers from denying coverage or charging higher premiums because of a person’s pre-existing medical conditions.

Those numbers apparently chased Ms. Murkowski away.

“There’s enough chaos and uncertainty already, and this would just contribute to it,” she said.

Republican leaders in Congress originally intended to proceed with a similar “repeal and delay” strategy in January. But Mr. Trump, among others, insisted that the repeal and replacement of the law be simultaneous.

It was unclear whether Mr. McConnell would even be able to clear a procedural hurdle to get to a vote on the repeal-only measure. He faced the same math problem as with his own bill: He can afford to lose only two Republican senators, with Vice President Mike Pence breaking the tie.

Not only has he apparently lost three, Senators Collins, Murkowski and Capito, but he must wait for the return of an ailing Senator John McCain, Republican of Arizona.

Ms. Collins said she would vote against the procedural step.

“I do not think that it’s constructive to repeal a law that is so interwoven within our health care system without having a replacement plan in place,” she said. “We can’t just hope that we will pass a replacement within the next two years. Repealing without a replacement would create great uncertainty for individuals who rely on the ACA and cause further turmoil in the insurance markets.”

Mr. Portman all but joined her.

“If it is a bill that simply repeals,” Mr. Portman said, “I believe that will add to more uncertainty, and the potential for Ohioans to pay even higher premiums, higher deductibles.”

Dr. David O. Barbe, the president of the American Medical Association, which opposed Mr. McConnell’s bill, urged lawmakers to pursue a bipartisan approach on health care, saying, “The status quo is unacceptable.”

The Senate Democratic leader, Chuck Schumer of New York, invited Republicans to work with Democrats to improve the health law. He warned that passing a repeal-only measure “would be a disaster,” saying it would cause millions of people to lose coverage and, in many ways, would be worse than Mr. McConnell’s original bill.

“It’s like if our health care system was a patient who came in and needed some medicine,” Mr. Schumer said. “The Republicans proposed surgery. The operation was a failure. Now Republicans are proposing a second surgery that will surely kill the patient.”

Governors From Both Parties Denounce Senate Obamacare Repeal Bill

PROVIDENCE, R.I. — The nation’s governors, gathered here for their annual summer meeting, came out strongly on Friday against the new Senate bill to repeal the Affordable Care Act, turning up the pressure on Republican leaders struggling to round up the votes to pass the bill next week.

Opposition came not just from Democratic governors but from Republicans who split along familiar lines — conservatives who said the legislation did not go far enough and moderates who said it was far too harsh on their state’s vulnerable residents.

Gov. Brian Sandoval of Nevada, who at the moment may be the most pivotal figure in the health care debate, said he had “great concerns” with the legislation, and all but declared that he could not support any bill that would scale back Nevada’s Medicaid program. His decision to expand Medicaid under the Affordable Care Act had been “a winner for the people of our state,” he said of the government health insurance program for poor and disabled people.

“I have to be comfortable that those 210,000 lives are going to continue to enjoy the quality of life and health care that they have right now,” he said, referring to the number of Nevadans who gained coverage through the expansion of Medicaid under President Barack Obama’s signature health law.

Conservative governors were not much more supportive. Gov. Scott Walker of Wisconsin suggested that Congress consider a better-funded version of the measure proposed this year by two Republican senators, Susan Collins of Maine and Bill Cassidy of Louisiana, that would offer states more flexibility over how to run their health care programs.

Pursuing that approach, Mr. Walker said, would obviate differences between the states that did and did not expand Medicaid while averting the intractable split between conservative and centrist members of Congress over how to structure a replacement. “None of these plans right now do us justice,” he said.

The response mirrored the struggles of congressional Republicans to forge consensus on legislation that would make good on a seven-year vow to repeal the health law. With two Senate Republicans already opposed, Senate leaders cannot lose any additional votes, and on Friday, some of the most influential Republican governors indicated a willingness to torpedo the bill entirely.

Mr. Sandoval’s views are likely to influence Nevada’s Republican senator, Dean Heller, while Mr. Walker’s could play on Wisconsin’s undecided Republican, Ron Johnson.

Recognizing how crucial Mr. Sandoval is, an array of senior federal officials planned to meet with him in Providence for 11th-hour lobbying. The National Governors Association conference, which more typically includes as much recreation as work, attracted Vice President Mike Pence, Health and Human Services Secretary Tom Price and Seema Verma, the administrator of the Medicaid program.

And in a sign of the furious efforts in Washington, Mr. Sandoval revealed that he had been lobbied personally by President Trump in a phone call. Mr. Sandoval declined to discuss the specifics of their discussion, which he said took place after his high-profile announcement last month with Mr. Heller that both would oppose an earlier version of the Senate bill.

Governors Scott Walker of Wisconsin and Matt Bevin of Kentucky, both Republicans, on Friday at the National Governors Association meeting, where they and other conservatives strongly criticized the Senate’s latest health care bill. CreditBrian Snyder/Reuters

Several of Mr. Sandoval’s Republican colleagues, from states that expanded Medicaid programs under the Affordable Care Act, were even more definitive in their opposition.

Gov. Phil Scott of Vermont, who won election in November even as Hillary Clinton carried his state by more than 20 percentage points, said the bill could cripple the health care system in Vermont.

“We’ve expanded Medicaid, and even a small tweak could have a devastating impact on us as a state,” Mr. Scott said. “We’ve made great strides at protecting the most vulnerable and I believe, in its present form, this would not be good for Vermont.”

Gov. Matt Bevin of Kentucky, who first emerged as a Tea Party-inspired challenger to Senator Mitch McConnell, the majority leader, came at the bill from the right. He sharply criticized his party’s decision not to eliminate a pair of taxes on high earners in the latest version of the bill.

“They’re going to lose as many votes as they’re getting,” Mr. Bevin said of the decision to keep the levies imposed by the Affordable Care Act. There was, he said, an “understanding that those two taxes were going to be gone.”

The governors have been playing an outsize role in shaping the congressional debate, with Republicans from states that expanded Medicaid often supplying the loudest voices. But some of the statehouse advice has plainly started to grate on Republican members of Congress.

“I don’t want to be irreverent, but, you know, people talk about their governors back home, are you kidding me?” said Senator Bob Corker of Tennessee. “I mean, if we can’t even deal with our governors back home, how will we ever deal with Medicare and Social Security?”

Every governor, Mr. Corker claimed, “would love for us to send free, unpaid-for money back home.”

Mr. Pence was notably more diplomatic as he spoke to the governors on Friday afternoon. He acknowledged the deep reservations in the room but branded the Senate bill a “rescue” measure. Mr. Pence detailed problems with the Affordable Care Act in Wisconsin and Ohio, two states where Republican governors have criticized the bill — and a pair of Republican senators, Mr. Johnson and Rob Portman, are wavering.

Mr. Pence, who as Indiana’s governor accepted federal funding to expand Medicaid, also acknowledged that the proposal would significantly change the population that receives health care coverage through the program. He insisted that the bill would hold Medicaid to its “original purpose” of covering the most severely vulnerable people and said too many “able-bodied adults” relied on the program.

The shift, he said, was aimed at “ensuring for the long run that Medicaid will be there for the neediest.”

Senator Bob Corker, Republican of Tennessee, on Thursday on Capitol Hill. He expressed frustration with the pressure from governors against the Senate bill to repeal the Affordable Care Act.CreditMichael Reynolds/European Pressphoto Agency

“I really believe, as the president does, that we’re saving Medicaid,” Mr. Pence said.

It is unclear that such arguments are likely to move governors like Mr. Sandoval, who have resisted any pullback of Medicaid coverage.

And in a gentle gibe, Gov. Terry McAuliffe of Virginia, a Democrat who is chairman of the National Governors Association, noted in introductory remarks that Mr. Pence had been glad to take Medicaid funding when he was a governor.

“He showed true backbone himself in Indiana,” Mr. McAuliffe said, “when he expanded Medicaid for his citizens.”

Among Democratic governors, opposition to the legislation was unanimous and fierce, and party leaders declared anew on Friday that Democrats would pummel any Republican who dared support the bill in the more than three dozen governors elections unfolding over the next year and a half.

Gov. Dannel P. Malloy of Connecticut, the chairman of the Democratic Governors’ Association, accused Republicans in scorching language of being willing to let “people die in your state because they’re no longer eligible for health care.”

Other Democrats took a gentler approach, coaxing Republican senators from their states with do-the-right-thing appeals. Gov. John Bel Edwards of Louisiana invoked Mr. Cassidy’s years of work as a doctor in their state’s charity hospitals.

“They’re not just constituents that he and I have in common; these are the same people that he spent his adult life taking care of, and he knows how important it is for them to have meaningful access to quality health care,” Mr. Edwards said.

Gov. John Hickenlooper of Colorado, a Democrat, said he hoped his state’s Republican senator, Cory Gardner, would listen to his better angels and oppose the bill, calling Mr. Gardner “a compassionate and smart person.”

Mr. Hickenlooper, while saying he had no specific plans for the future, also declined to quash recent murmurs in Democratic political circles that he might challenge Mr. Gardner for re-election in 2020 if the senator votes in favor of the bill.

“This is something that matters a lot to me,” he warned.

What many Republicans fear is that action on what they have long derided as Obamacare also matters a great deal to their base. Failing to find consensus and act could prove just as risky politically, some here said.

“I do have concerns when Republicans have the House, the Senate, the presidency and 33 governorships across the country if we don’t govern,” Gov. Doug Ducey of Arizona said. “I think it’s time to lead and govern.”

The Republican Party’s quest to repeal Obamacare is on the verge of collapse



Washington (CNN) Republican senators returning to Washington Monday sounded exasperated and downright deflated about their unpopular bill to overhaul the health care system.

Some are even beginning to wonder out loud what was an unthinkable prospect a year ago: the GOP could be forced to ditch its efforts to get rid of Obamacare.
“Better than 1%. Not yet above 2% in my opinion,” a senior Republican source told CNN on the chances the health care bill will pass Senate at this point.
Fresh off the recess, members seemed to be unclear on how Majority Leader Mitch McConnell could bridge the divide within the conference.
“I think we have the information we would need if we’re willing to use it. If we’re willing to be honest about what has caused the collapse of these markets and address it forthrightly, not being concerned about the political implications, but actually fix the problem,” said Sen. Ron Johnson, a Republican from Wisconsin who has been vocal about his frustration with the process. “I think we have the information to address it. I’m not sure we are going to address it, and that is enormously frustrating for me.”
At Tuesday’s Senate GOP policy lunch, the first real indications of the week on which direction leadership is moving may emerge — and it’ll be an opportunity for leaders to take the temperature of the conference on how they’re feeling after the hiatus.
Maine Sen. Susan Collins insisted that barring a “complete overhaul” of the current bill, she simply couldn’t support the legislation. She too called for bipartisan dialogue.
“I don’t want to see us make the same mistake and pass an overhaul of the law without a single Democratic vote,” the GOP moderate said on Monday. “We get far better legislation when both parties work in good faith to reach a solution.”
Arizona Sen. John McCain was characteristically blunt: The Senate bill is on its last legs, he said, and Republicans should think about joining forces with Democrats.
“My view is it’s probably going to be dead,” McCain said Sunday on CBS’s “Face the Nation.” “If you shut out the adversary or the opposite party, you’re going to end up the same way Obamacare did when they rammed it through with 60 votes. Only guess what? We don’t have 60 votes.”
One aide to a Republican senator closely involved in health care negotiations said Senate Republicans were simply not “any closer” than they were before recess, and that for now, it was hard to see the path to 50 “yes” votes.
“It’s easy to get to 40 or 42 yes’s,” the aide said. “Getting to 50? I don’t know.”
Sen. Ernst grilled about health care

Sen. Ernst grilled about health care 03:01

What conservatives want

The crux of the issue is finding a way to get moderates and conservatives on the same page. Conservatives want to repeal more Obamacare regulations. Moderates want to ensure that protections for people with pre-existing conditions remain. They also want to preserve Medicaid expansion for as long as they can.
Conservatives like Sens. Ted Cruz and Mike Lee have been pushing to try and give insurers more flexibility in the plans they offer in the health care marketplace, but moderates have concerns the amendment could gut protections for those with pre-existing conditions. And many members acknowledged that the Cruz amendment may not be the magic fix to get to 50 votes.
Kids make journey to confront lawmakers

Kids make journey to confront lawmakers 03:06
“I think it picks up conservative votes and loses other votes,” said Sen. Chuck Grassley, a Republican from Iowa.
Sen. Roger Wicker of Mississippi said he could support the Cruz amendment, but that “It’s not a showstopper or a game changer.”
The sagging mood among Senate Republicans marks a new low point for McConnell, who had hoped to vote on the health care bill before members leave town against for the August recess. But the week-long Independence Day break only seemed to intensify his colleagues’ concerns about the health care bill, with a 10th Republican — Kansas Sen. Jerry Moran — coming out against it.
With 52 Republicans in the Senate, McConnell faces the daunting task of convincing most of his colleagues who are currently opposed to the bill to change their minds.
And in a Monday morning tweet, President Donald Trump laid out a suggested deadline: A bill on his desk before August recess.
“I cannot imagine that Congress would dare to leave Washington without a beautiful new HealthCare bill fully approved and ready to go!” the President wrote.

Working with Democrats?!?

Perhaps in an acknowledgment of the tough road ahead, McConnell himself also raised the prospect of the undesirable outcome: if Republicans fail to pass a repeal and replace legislation, they may need to work with Democrats to make fixes to Obamacare.
“If my side is unable to agree on an adequate replacement, then some kind of action with regard to the private health insurance market must occur,” McConnell said in Kentucky last week. “No action is not an alternative.”
If McConnell was reluctant to delay a vote until after the July 4 recess, he will be even more unwilling to let health care drag out beyond the end of July, when lawmakers take off the full month of August until after Labor Day. Prolonging the debate further would seriously jeopardize the GOP’s other legislative priorities, and leadership has made clear that some decision will have to be made in the next few weeks.
Republican Sen. John Cornyn told reporters on Monday that leadership hopes to unveil a bill as early as this week and have votes next week. According to one Senate aide, leadership hopes to unveil a revised draft legislation by Thursday and receive an updated score from the Congressional Budget Office early next week.
McCain GOP health care bill probably dead nr_00000000

McCain: GOP health bill probably dead 01:10
“I’m for getting our work done now. I don’t think stringing it out longer than next week helps us with the product,” Cornyn said.
Asked whether the bill would be brought up on the Senate floor knowing that it would fail, Cornyn responded: “I never go into a fight expecting to lose so I would expect to win.”
Sen. Bob Corker, a Republican from Tennessee, joked with reporters bombarding him with questions about the future of health care.
Asked Senate leaders would bring the bill to the floor if they knew it would fail, Corker joked, “I’m feeling pretty good today. I did yoga this morning.”

Emotional Donald Trump supporter (White Idiot) explains that his family ‘won’t be insured’ if Obamacare goes away



An emotional Donald Trump supporter on Tuesday told CNN’s Don Lemon he wouldn’t be able to afford health insurance if it weren’t for Obamacare, the signature legislation the president has promised to repeal.

Lemon also spoke with pastor and veteran Janice Hill, whose daughter would have died without the Affordable Care Act.

“You’re a life long republican, yet you and your wife are insured through Obamacare,” Lemon said to guest Don Riscoe. “What will happen to that insurance if Obamacare is repealed?”

“We probably won’t be insured,” a visibly upset Riscoe replied.

“You okay?” Lemon asked.
“Yes,” he said. “We won’t be insured if Obamacare goes away. We won’t be able to afford premiums.”

“I know we can’t afford $1,000 a month,” he continued. “I don’t know the exact number but … we wouldn’t be able to afford coverage without the infrastructure.”

Riscoe said Obamacare “does have problems” that need to get fixed. “I hope that there’s something that will be in place that we can still have coverage for myself and a lot of others,” Riscoe said.

Pastor Hill told Lemon the bill’s plan to slash funding for Medicaid is really what’s going to hurt.
“When they take away Medicaid, it’s not only going to hurt my daughter who is not on Medicaid now because she’s working full time, but it’s going to hurt the people in my state. It’s going to hurt veterans, which i’m a veteran. Ten percent of veterans are on medicaid.”

“It’s going to hurt the employment rate,” she continued. “It’s going to hurt people’s access to health coverage. They’re not going to go for any kind of preventive care. It’s going to be critical when they do go. It’s going to cost more money. This bill doesn’t make sense.”