Obamacare repeal plan needs Republican balance to pass

Senate Republicans must stamp out a series of fires to keep their Obamacare repeal mission alive this week, such as pinning down party holdouts and massaging arcane budget rules to appease pro-life activists and insurers.

Republican moderates say a pending analysis by the Congressional Budget Office, set to be released at any moment, will help them decide whether they back the draft plan negotiated by Senate Majority Leader Mitch McConnell, reject it or demand changes before a planned vote by the time lawmakers leave for their July Fourth recess.

One of them — Sen. Dean Heller of Nevada — made the leadership’s climb steeper on Friday by becoming the fifth Republican to say he won’t support the plan unless changes are made. He said his state cannot absorb Medicaid cuts in the plan.

“There are some things we’ve said all along that are dial-able, that I think we can hopefully tweak a little bit,” Sen. John Thune, South Dakota Republican and member of the leadership team, said after Mr. McConnell revealed the draft plan to his Republican troops.

Yet like a Rubik’s cube, tweaking the plan to suit moderates will redraw the debate for conservatives, who say the plan needs changes to win their support.

Sen. Rand Paul of Kentucky is the most entrenched, saying the plan looks too much like Obamacare. Sen. Ted Cruz of Texas circulated a wish list to Republican colleagues on how he can get to “yes,” such as allowing insurers to offer plans that don’t comply with Obamacare’s insurance rules as long as they provide other ones that do.

Sen. Mike Lee of Utah said the Republican bill “keeps the Democrats’ broken system intact.” He said states should be free to abandon Obamacare and adopt their own models of health care. For instance, liberal states might pursue government-run, single-payer insurance and conservative states might emphasize tax-advantaged health care savings accounts.

Another Republican holdout, Sen. Ron Johnson of Wisconsin, said the Senate is rushing, so he might reject a procedural motion to proceed with the bill this week.

“What I’d like to do is slow the process down, get the information, go through the problem-solving process, actually reduce these premiums that have been artificially driven up because of Obamacare mandates. So, let’s actually fix the problem,” Mr. Johnson told NBC’s “Meet the Press.”

Mr. McConnell, Kentucky Republican, can afford to lose only two senators from his 52-seat majority and still pass a bill under budget rules that allow him to avoid a Democratic filibuster, so the plan is already in doubt.

Sen. Susan M. Collins of Maine is also on the fence, saying she is worried that older Americans will have to pay more and that she won’t be able to strip out a part of the bill that defunds Planned Parenthood over its abortion practice.

“It makes absolutely no sense to eliminate federal funding for Planned Parenthood,” Ms. Collins told ABC News, noting that federal funds cannot be used directly for abortion anyway.

However, axing that part of the bill would dispirit pro-life lawmakers in the House who passed their own bill in March and must revisit the Senate’s rewrite before Congress puts a bill on President Trump’s desk.

Mr. Trump confirmed on Sunday that he has called the House version “mean,” though he is cautiously optimistic that Senate Republicans can approve a bill with “heart.”

“Health care is a very, very tough thing to get,” the president said on Fox News. “But I think we’re going to get it. We don’t have too much of a choice, because the alternative is the dead carcass of Obamacare.”

Sen. Charles E. Schumer, New York Democrat, put the Republicans’ odds at 50-50. He argued that some Republicans were worried about reining in Obamacare’s vast expansion of federally subsidized health care.

The 142-page plan would extend the life of President Obama’s Medicaid expansion and offer more generous subsidies for the poor and those approaching retirement age than the House plan.

Yet to placate fiscal hawks, the plan would allow Medicaid spending to rise at a slower rate than in the House version, starting in 2025. Republicans say reining in Medicaid spending would force states to focus on those who need it most, though moderates worry that the cuts would yank coverage from needy residents and cripple the fight against opioid addiction.

“The bill is just devastating. And that’s what’s making it so hard for them to pass it,” Mr. Schumer told ABC News. He said Democrats will continue to fight any repeal effort and push for bipartisan talks on Obamacare’s wobbly markets.

Though a wily negotiator, Mr. McConnell faces procedural headaches, such as fending off politically painful votes on amendments and satisfying the Senate’s referee, the parliamentarian, who might strike language that is not relevant to the budget process.

Senate language barring consumers from using tax credits for abortion might not pass the vetting process known as a “Byrd bath,” forcing Republicans to funnel the money through an existing federal program that prohibits spending on the procedure.

If pro-life language doesn’t make it into the final package, “I think that blows the thing to Mars,” said Rep. Trent Franks, Arizona Republican.

Health insurers are weighing the pros and cons of the draft plan too. They cheered funding for “cost sharing” reimbursements through 2019, the repeal of a tax on their industry and a stability fund to help the markets transition to a new program through 2021.

“All of that will help immediately to make coverage more affordable, especially for young and healthy people,” said Kristine Grow, a spokeswoman for America’s Health Insurance Plans, a key insurers lobby.

Yet insurers are worried about sweeping cuts to Medicaid because managed care plans rely on reimbursements from the program, and the Senate draft doesn’t include an incentive for people to enroll and start paying premiums before they need medical care.

The Republican plan scraps penalties tied to Obamacare’s “individual mandate” requiring people to hold insurance, and the House version would impose a yearlong surcharge on the premiums of people who experience a lapse in coverage for 63 days or more.

The Senate doesn’t include a continuous coverage provision, though Republican aides said they are trying to include one if the parliamentarian will allow it.