Majority Leader Senator Mitch McConnell (R-KY) is bound and determined to have a vote on the Senate ACA repeal bill by the end of this month. The logic is that the Senate needs to move the issue one way or another so that the rest of the legislative year and priorities such as a tax cuts are not consumed by the health care debate. The goal of a vote in the Senate by the July 4th break also appears to be in line with the comments and proposed strategies the President announced after meeting with members of Congress last Tuesday.

Republican Senators had their first joint discussion since the Memorial Day break when they held their Tuesday policy luncheon this past week.  Members viewed a PowerPoint discussion and Republican members seemed to be more optimistic after they left the gathering.

To stick to that timetable, the Senate needs to have a draft bill in a matter of days because the Congressional Budget Office (CBO) must have a cost projection before a Senate vote. Observers expect such a CBO analysis would take up to two weeks.

The House reconciliation bill containing the American Health Care Act overcame a technical hurdle when it was cleared by the Senate parliamentarian as meeting certain key reconciliation rules. This is not, however, the same as a determination of which provisions of the House bill violate the Senate’s “Byrd Rule.” There is a very technical six-part test of whether legislative provisions of the House bill or Senate bill to determine whether a provision in the bill is “merely incidental” to the main goal of a reconciliation: reducing federal spending.

Movement and Contention

The past week was filled with signals of movement and fights. The Hill reported that the parliamentarian has determined that House bill language on restrictions regarding health care coverage of abortion may have to be stripped because it violates the Byrd rule (i.e., doesn’t have a spending impact). That could make some conservatives nervous, especially if the bill does not provide a flat-out repeal of the ACA.

In a boon for Senate Republicans and opponents of the Affordable Care Act, some of the more moderate Senate Republicans, including Senator Dean Heller (R-NV) and Senator Rob Portman (R-OH), have indicated publicly that they could support a bill that allowed a slower phase-out of the Medicaid expansion. Majority Leader McConnell has promoted a three-year phase-out, while these two senators indicated that a seven-year phase-out may be acceptable to them.

For some senators, a central sociopolitical issue appears to be the increase in addiction to opioids. The Ohio Attorney General has just filed a suit against some drug manufacturers over the spread of opioids, and in that filing indicated that 70 percent of the infants entering Ohio’s foster care system are entering because of a parent’s opioid addiction.

Other senators, including Majority Leader McConnell, are focused on the spread of opioids and the need for increased drug treatment. This is a remarkable departure from the 1980s response to the crack epidemic—which was prevalent in the nation’s urban centers compared to more rural and suburban spread of opioids in this decade. In the 1980s, the politics drove the country toward more law enforcement and tougher and longer sentencing rather than increased drug treatment and support for those who fall victim to addiction.

Senator Portman indicated to Roll Call that he was pushing for a dedicated funding stream to address drug treatment. He told that publication that “[Medicaid] is the major payor for the kind of drug treatment that is necessary right now with the opioid crisis and so many people being addicted.  The alternative is bad for those individuals and their families but also more expensive for taxpayers.”

After the Congressional Budget Office (CBO) issued the new assessment of the American Health Care Act that showed that the amendments made to the original bill costs $32 billion more and will reduce the number of uninsured under the original bill by only 1 million people, CWLA released a letter of opposition based on the modifications. Members are urged to use and adapt the information in that statement, which focuses heavily on how the ACA has expanded access to mental health and substance use treatment.

On a more positive note, CWLA has endorsed a new bill by Senator Dianne Feinstein (D-CA) S. 1307, which would modify the way subsidies are phased out for people making more that the cap of 400 percent of poverty. Under the current law an individual making one dollar more than 400 percent of the poverty level loses all federal assistance/subsidies. The new bill would phase out the subsidy.

All such legislation, however, would become moot if Medicaid is turned into a block grant or per capita cap.