Senate Majority Leader Mitch McConnell (R-KY) will delay a critical key procedural vote this week after Senator John McCain (R-AZ) announced he would be absent due to a medical procedure. That will not prevent McConnell from trying to get the necessary votes but will likely delay it at least a week.  Once the Senate approves a motion to proceed it could lead to the all-important final vote on a bill to supplant the ACA.

The original pre-4th of July  Better Care Reconciliation Act was replaced on Thursday, afternoon with a revised version that maintains the severe cuts (or “reduction in the rate of growth”) to Medicaid, adds a provision similar to what Senator Ted Cruz (R-TX) has been seeking and supplements some of the previous cuts with funds to address state insurance and private insurance subsidies and funding for drug treatment.

Senator McConnell will try and get 50 of his fellow Republican members to allow for the motion to proceed to the bill.  That would in turn start the 20-hour debate clock before a final vote.  Senator McConnell is sure to push his members to at least allow the debate to move forward arguing they should do so even if they don’t support the measure.

That would then open the door to amendments and give the Leader more time to place fixes in the bill that can attract those ten to twelve members who have expressed some reservations.

The next step now is the release of an updated Congressional Budget Office evaluation not expected for a few days.  The CBO will be adjusting based on the changes that include:

  • $45 billion in funding for drug (opioid) treatment
  • Re-inserting some of the taxes (investor and Medicare payroll taxes)
  • More funds for state-based initiatives to drive down costs
  • More funds to offset premium increases
  • More Medicaid funds if HHS designates a health emergency
  • The “Cruz” amendment that would allow insurance companies to offer cheaper plans that do not meet the ACA standards

What it doesn’t do is change the Medicaid cuts from the original bill.  It still includes the per capita caps and the optional state Medicaid block grant. CBO is being asked to do more than one score.  One will include the version of the Senator Ted Cruz amendment and one may be without the modification.

The Cruz plan allows a company to offer one plan that meets the standards of the ACA and provides coverage for important services such as mental health and substance abuse services and a second that is a bare-bones policy that covers very little but has cheap premiums.  The concern is that you end up with all the sicker and older populations in one expensive insurance pool and you end up with a younger and healthier population in the cheap limited coverage pool. Over the weekend two key insurance groups, representing Blue Cross-Blue Shield and the private insurance companies, came out in opposition the Cruz-like proposal.

One of the keys to the success and strategy for the ACA expansion has been to increase the number of “young invincible” those people under 30 who are generally much healthier and who as a result can spread the cost of health insurance across the entire health care population.

It is believed that if the CBO finds such a Cruz approach would cost-out some older and sicker people and make premiums unaffordable, Senate leaders may drop it from their bill.  The Senate keys continue to be Senators Collins (R-ME), Murkowski (R-AK), Portman (R-OH), Flake (R-AZ), Capito (R-WVA), Heller (R-NV) and perhaps a few others such as Moran (KS) and Hoeven (R-ND) as well as Senator Ron Paul (R-KY) who opposes the current bill because it does not include a full repeal.

After the CBO score and analysis, if it is not devastating to Senator McConnell’s efforts, he will push for 50 votes to start the 20-hour debate clock sometime after McCain returns. If and when the Senate does approve the bill, expect the House to take up the measure in days with the likelihood of passage.

To send a letter of protest to your two United States Senators and Member of Congress go to the new CWLA Action Center type in your zip code and pull up a draft letter ready to send.