Five things to watch in Senate GOP’s ObamaCare repeal bill

Five things to watch in Senate GOP’s ObamaCare repeal bill
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A draft of the long-awaited Senate healthcare bill, crafted behind closed doors, will be publicly unveiled on Thursday.

Just a day before the bill’s scheduled release, some senators said they still didn’t know the details of some key provisions, creating uncertainty as Senate Majority Leader Mitch McConnellAddison (Mitch) Mitchell McConnellDoug Jones walks tightrope on Supreme Court nominee Kavanaugh gets questionnaires for confirmation hearing Dem infighting erupts over Supreme Court pick MORE (R-Ky.) pushes toward a vote next week.

Here’s what to watch for. 

How does it handle Medicaid?

ObamaCare’s Medicaid expansion has long been one of the thorniest issues for Republicans in their push to repeal the law.

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GOP senators from states that took the expansion, and their governors, don’t want to see their residents lose coverage. The Affordable Care Act gave states that expanded Medicaid extra money to do so, and lawmakers from those states worry ending this funding too early could be
problematic.

The House-passed healthcare bill would end extra Medicaid expansion dollars in 2020, but some senators have pushed for a longer transition. Leadership recently proposed a three-year transition beginning in 2020, but a contingent of moderate senators is advocating for a seven-year phaseout.

Two lobbyists told The Hill that the phase-out in the draft is likely to be over three years, but that timeline could be increased to five years next week if necessary to garner the support of more moderates.

And when asked about a three- and seven-year phaseout, Sen. John ThuneJohn Randolph ThuneGOP senators introduce resolution endorsing ICE The real reason Scott Pruitt is gone: Putting a key voting bloc at risk Hillicon Valley: Lawmakers eye ban on Chinese surveillance cameras | DOJ walks back link between fraud case, OPM breach | GOP senators question Google on Gmail data | FCC under pressure to delay Sinclair merger review MORE (S.D.) — the Senate’s No. 3 Republican — said it would be closer to the latter.

According to a Senate GOP aide, Medicaid expansion will phase out over four years, from 2020 to 2024 with extra federal dollars first reducing in 2021. 

 The Senate bill is also likely to have deeper cuts to Medicaid than the House bill. The growth rate for a new cap on Medicaid spending levels would start the same as the House bill, but in 2025 would drop to a lower growth rate.

“I don’t support lowering the annual growth rate from where the House is,” Sen. Rob PortmanRobert (Rob) Jones PortmanGOP moderates hint at smooth confirmation ahead for Kavanaugh Sens introduce bipartisan bill matching Zinke proposed maintenance backlog fix On The Money: Trump backs off investment restrictions on China | McConnell opens door to tariff legislation | Supreme Court deals blow to public-sector unions, ruling against 'fair-share' fees MORE (R-Ohio) said Wednesday. “The cost of Medicaid laid out by [the Congressional Budget Office] and also [the Centers for Medicare and Medicaid Services], cutting the growth rate will mean that states won’t be able to keep the same number of people on Medicaid without buying additional resources, and that’s a challenge.”

Are there provisions on abortion?

Defunding Planned Parenthood is important to some conservative
senators.

But preserving that funding is important for Republican Sens. Lisa MurkowskiLisa Ann MurkowskiDem infighting erupts over Supreme Court pick McConnell: Senate to confirm Kavanaugh by Oct. 1 Overnight Energy: House to vote on anti-carbon tax measure | Dem says EPA obstructed 'politically charged' FOIA requests | GOP looks to overhaul endangered species law MORE (Alaska) and Susan CollinsSusan Margaret CollinsDem infighting erupts over Supreme Court pick McConnell: Senate to confirm Kavanaugh by Oct. 1 Overnight Health Care: Watchdog finds Tom Price improperly used funds on flights | Ex-Novartis CEO sent drug pricing proposal to Cohen | HHS staffers depart after controversial social media posts MORE (Maine), two crucial swing votes.

The initial draft of the legislation is expected to defund Planned Parenthood, but that language may have to be taken out for the bill to ultimately pass.

One abortion-related provision that likely won’t be allowed: the House’s ban on tax credits going toward plans that cover abortion. The provision is likely to be stripped out because it is said to fall short of the budgetary rules Republicans are using to repeal and replace ObamaCare and avoid a Democratic filibuster.

“I believe that did not pass through the parliamentarian’s review, so I don’t expect that to be in there,” Collins said Wednesday. 

How does it deal with pre-existing conditions?

The House bill has a waiver that would allow states to opt out of key ObamaCare insurance regulations — the provision was added to secure conservative support for the legislation, known as the American Health Care Act.

 But the waivers are controversial. In an analysis of the House-passed bill, the nonpartisan Congressional Budget Office (CBO) said the waivers allowing insurers to charge people more money based on their health status could price sick people out of the markets.

Going into this week, many expected that the change to the rules for pre-existing conditions would not survive in the Senate bill. On the other hand, reports suggested senators would keep a waiver permitting states to opt out of requiring insurers to cover a list of services, such as maternity and mental healthcare.

But it’s not entirely clear what will happen.

Asked about community rating waivers, Thune said, “I don’t think that’s a final decision made yet, but I would guess that’s unlikely.”

Senate Majority Whip John CornynJohn CornynRussians' indictment casts shadow ahead of Trump-Putin summit Top GOP senator: Trump should be 'clear-eyed' going into meeting with Putin Doug Jones walks tightrope on Supreme Court nominee MORE (R-Texas) seemed to indicate Wednesday that the Senate bill would not touch pre-existing
conditions.

“We’re going to try to send a lot of the authority back to the states and let them design the packages that suit their needs,” he said, “but we’re not going to do anything to change the current law when it comes to pre-existing conditions. I know which was a big concern with the House bill.”

How are the tax credits structured?

The House bill would provide low- and middle-income people  who don’t receive health coverage through work or a government program a tax credit to help cover their premiums, with the amount increasing
by age.

The GOP received flack for how the provision would impact older adults. For example, a 64-year-old making $26,500 per year would pay more than half their salary in premiums, according to the CBO estimate.

The Senate bill is likely to beef up the tax credits, particularly for older adults.

For months, Thune has been examining tying the subsidies to age and income. So, Senate Republicans are expected to keep ObamaCare’s tax credit structure, just make them less generous. But it will provide more help to lower-income and older adults than the House bill did.

Sen. Rand PaulRandal (Rand) Howard PaulRand Paul ‘concerned’ about Kavanaugh Rand Paul on Russia indictments: We should focus on protecting elections instead of 'witch hunt on the president' Sunday shows preview: Trump readies for meeting with Putin MORE (R-Ky.), a conservative who has had harsh words for elements of the bill, has decried the refundable tax credits as “new
entitlements.”

“Ninety percent of the ObamaCare subsidies remained in the House bill, and they’ve been adding to them,” he told reporters Wednesday. “What I’m very, very suspicious of is that when we add them up tomorrow there’s a possibility we could have more subsidies than ObamaCare has.”

Does it contain opioid funding?

Many parts of the country are in crisis due to record deaths from heroin and prescription painkiller abuse.

Some states, such as Ohio and West Virginia, have been hit particularly hard by the epidemic, and their GOP senators want $45 billion over 10 years to fund opioid treatment in the ObamaCare repeal-and-replace bill. The theory is this money could help offset Medicaid cuts, as many Medicaid recipients are now receiving addiction treatment through the program.

But a lobbyist familiar with the negotiations said the opioid money is unlikely to be included in the bill.

Another addiction treatment advocate wrote in an email that staffers from states dealing with opioid deaths are working to add the money to the bill. Without it, some senators might vote against the legislation. 

Peter Sullivan and Jessie Hellmann contributed.