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Washington • Senate Republicans suffered a dramatic failure early Friday in their bid to advance a scaled-back plan to overhaul the Affordable Care Act, throwing into question whether they can actually repeal the 2010 health law.
Their latest effort to redraw the ACA failed after Sen. John McCain's decision to side with a couple of other Republicans against President Trump and GOP leaders. The Arizona Republican, diagnosed with brain cancer last week, returned to Washington Tuesday and delivered a stirring address calling for a bipartisan approach to overhauling the ACA, a process that may have compelled McCain to cast his rebellious vote.
The count was 49 to 51, with Utahns Orrin Hatch and Mike Lee voting yes on the measure.
Senate Majority Leader Mitch McConnell, R-Ky., had hoped to approve the new, narrower rewrite of the health law at some point Friday, after facing dozens amendments from Democrats. But the GOP defections left McConnell without a clear bill to push.
McCain had been seeking an iron-clad guarantee from House Speaker Paul Ryan, R-Wis., that, if the Senate approved this latest proposal, the House would not move to quickly approve the bill in its current form and instead engage in a broad House-Senate negotiation for a broader rollback of the law. Ryan issued a statement intended to assuage the concerns of McCain and two others, Sens. Lindsey Graham, R-S.C., and Ron Johnson, Wis., but the 2008 presidential nominee deemed the speaker's statement as insufficient.
The standoff between the two chambers highlighted the extent to which Republicans have still not reached a consensus on how to rewrite President Barack Obama's 2010 health care law, and the degree to which Republicans are repeating many of the same back-room maneuvers that Democrats used seven years ago to approve the ACA.
McConnell's draft rattled both moderates - Sens. Susan Collins, Maine, and Lisa Murkowski, Alaska, were the other Republican votes in opposition - and Republicans who wanted a more robust uprooting of the existing law.
"I'm not going to tell people back in South Carolina that this product actually replaces Obamacare, because it does not, it is a fraud," Graham said at a Thursday evening news conference with McCain and Johnson at his side.
And while GOP senators insisted the bill they were considering would not make it into law, if enacted it would make sweeping changes to health coverage as well as medical treatment in the United States.
It would eliminate enforcement of the ACA's requirement that Americans obtain insurance or pay a tax penalty, and suspend for eight years enforcing the mandate that companies employing 50 or more workers provide coverage.
The measure also would eliminate funding for preventive health care provided under the 2010 law and prohibit Medicaid beneficiaries from being reimbursed for Planned Parenthood services for one year. Instead, the federal funding that would have gone to Planned Parenthood would go to community health centers. It would end a 2.3 percent tax on medical device manufacturers for three years.
And it would empower federal officials under an existing waiver program to give states wide latitude in how they allocate their Medicaid funding, potentially pooling that money with other programs such as one that helps lower-income Americans buy private insurance. It also would increase the limit on contributions to tax-exempt health savings accounts for three years.
After weeks of secretive negotiations, McConnell unveiled this draft only a couple of hours before what was expected to be a cliffhanger vote early Friday. Even after that critical vote, the legislation was subject to dozens, if not hundreds, of Democratic amendments in the hours ahead, before a final vote later Friday.
Shortly after it was introduced, the Congressional Budget Office issued an estimate finding that 16 million people would lose coverage and that premiums would rise roughly 20 percent a year between 2018 to 2026 compared to current law if Republicans enacted the pared-down bill.
Sara Rosenbaum, a health law and policy professor at George Washington University, said the bill would make "enormous" changes to private and public insurance.
Translating their pledge to repeal what they derisively call Obamacare into a law has proved embarrassingly difficult for Republicans. First, the House took an extra six weeks to pass its version of the bill in early May. Most Republicans agreed that the measure was flawed - Trump later called it "mean" for how it would deny insurance to 23 million people - and hoped that the Senate would craft a better bill.
But McConnell's closed-door negotiations ended in gridlock, leaving him to pull together this "skinny" repeal of the ACA, just to keep alive negotiations with the House to come up with a different plan later this summer.
"I'm not going to tell people back in South Carolina that this product actually replaces Obamacare, because it does not; it is a fraud," Graham said at a Thursday evening news conference with McCain and Johnson at his side.
McCain, who was diagnosed with brain cancer last week and returned this week calling for a bipartisan approach, was poised to be the critical vote on McConnell's new proposal, which has no Democratic support.
Many conservatives in both chambers object to the measure because they say it wouldn't go far enough in repealing the ACA.
For instance, the expansion of federal funding to use Medicaid to provide insurance to about 14 million Americans is left intact, a major victory for half a dozen Senate Republicans from states that accepted the additional money. Governors, under the new Senate proposal, would have more leeway in how they can spend Medicaid funding overall.
Major insurers are warning that the proposal could destabilize the individual insurance market. Blue Cross Blue Shield Association criticized it on Wednesday, and on Thursday the industry's largest trade group suggested it was unacceptable.
"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," America's Health Insurance Plans wrote in a letter to Senate leaders.
Senate Republicans, however, framed the bill as just a vehicle to keep alive their ACA repeal efforts.
"My sense is people aren't so much focused on the substance as they are this being the lifeline to get to a conference and expanding the bill," said Sen. Bob Corker, Tenn.
Before Ryan issued his statement, the prospect of an immediate up-or-down vote in the House raised alarms in the Senate. House Republican leaders instructed their members not to leave town for their month-long summer recess just yet.
Key House conservatives said they would not back a skinny repeal in its current form. Rep. Mark Meadows, R-N.C., chairman of the House Freedom Caucus, said that he wouldn't vote for such a measure and that he didn't think other conservatives would, either.
Speaking on the Senate floor Thursday, McConnell emphasized that the votes this week would not reverse the ACA even if they culminate in the passage of a bill.
"One phase of that process will end when the Senate concludes voting this week, but it will not signal the end of our work. Not yet," he said.
In an effort to muster enough votes for a narrow bill, GOP leaders suggested that even some proposals that have died in the Senate could resurface once senators enter negotiations with the House. And some members tried to add a few more provisions to the skinny bill, using their leverage to try to strengthen their negotiating positions in conference.
While McConnell has led the negotiations over health care legislation for weeks, Trump has sought to drum up support by pressing wavering Republicans.
Interior Secretary Ryan Zinke called Sens. Dan Sullivan and Lisa Murkowski, both Alaska Republicans, separately Wednesday to warn them that the administration may change its position on several issues, according to people briefed on the conversations, given Murkowski's vote against proceeding with health care legislation this week.
Since Trump took office, Interior has indicated that it is open to constructing a road through the Izembek National Wildlife Refuge and drilling in the Arctic National Wildlife Refuge while expanding energy exploration elsewhere in Alaska. But now these policy shifts may be in jeopardy.
Speaking to reporters Thursday, Sullivan said the Trump administration has been cooperative on Alaska issues with Murkowski, who chairs the Senate Energy and Natural Resources Committee.
"From my perspective, the sooner we can get back to that kind of cooperation between the administration and the chairman of the ENR Committee, the better for Alaska and the better for the country," he said. Sullivan said he is not telling Murkowski how to respond.
The Alaska Dispatch News first reported the calls; Interior officials did not respond to a request for comment.