OPIOID SERIES:

New GOP health bill puts centrists in vise

The revised GOP ObamaCare replacement bill is testing the promises that centrist Republicans have made during the legislative debate.

Several moderate Republican senators previously raised alarm with an amendment from Sen. Ted CruzRafael (Ted) Edward Cruz32 male senators back Senate women's calls to change harassment rules Senate confirms Trump’s pick to lead NASA DOJ denies reports judicial nominee once called illegal immigrants 'maggots' MORE (R-Texas) that they worried would undermine protections for people with pre-existing conditions. They also expressed opposition to the deep Medicaid cuts in the bill.

Now, the Cruz amendment has been included in the bill and the Medicaid cuts remain, putting centrists on the spot. 

So far, Sen. Susan CollinsSusan Margaret CollinsOvernight Energy: Trump NASA pick advances after drama | White House office to investigate Pruitt's soundproof booth | 170 lawmakers call for Pruitt to resign Trump's NASA nominee advances after floor drama Family, friends mourn death of Barbara Bush MORE (R-Maine) is the only moderate to oppose the measure, with the others saying they are undecided and still reviewing it.

Whether leaders can flip these moderate Republican senators will decide whether the bill lives or dies. Collins and conservative Sen. Rand PaulRandal (Rand) Howard PaulHeitkamp becomes first Dem to back Pompeo for secretary of State Senate committee sets Monday vote even as Pompeo appears to lack support Trump checkmates Democrats in sending Pompeo to North Korea MORE (R-Ky.) have already announced their opposition, so one more “no” vote would sink the bill.   

Sen. Bill Cassidy (R-La.) has been one of the most vocal Republicans on the issue of protecting people with pre-existing conditions, touting the “Jimmy Kimmel test,” that no one should be denied care.

He praised the previous version of the bill, which did not include the Cruz amendment, as being “very cognizant of pre-existing conditions.” 

Cassidy says he is still reviewing and making up his mind about the revised bill.

The Cruz provision would allow insurers to sell plans that do not meet ObamaCare’s requirements, including the ban on discriminating against people with pre-existing conditions. Conservatives argue this would allow younger and healthier people to buy cheaper plans.

Moderates and many health experts, though, warn that only sick people would remain in the more generous ObamaCare plans, leading to price spikes for people with pre-existing conditions. That dynamic could make coverage prohibitively expensive for some.

Sen. Chuck GrassleyCharles (Chuck) Ernest GrassleyGrassley: McConnell doesn't control my committee Senate panel punts Mueller protection bill to next week GOP senator: Congress needs ‘to move on’ from Russia probe MORE (R-Iowa) warned earlier this month that the Cruz amendment could be “subterfuge to get around pre-existing conditions [protections],” according to Iowa Public Radio.

Now that the amendment has been included, Grassley’s office says he is studying the bill and awaiting an analysis from the Congressional Budget Office that is scheduled for release on Monday.

The revised bill does include $70 billion aimed at helping bring down costs for people with pre-existing conditions remaining in the ObamaCare plans.

But the inclusion of the amendment appears to break from the previous GOP line that protections for people with pre-existing conditions were not being touched.

“We're not going to do anything to change the current law when it comes to pre-existing conditions, I know which is a big concern with the House bill,” Sen. John CornynJohn CornynSenate confirms Trump’s pick to lead NASA DOJ denies reports judicial nominee once called illegal immigrants 'maggots' Overnight Energy: Trump NASA pick advances after drama | White House office to investigate Pruitt's soundproof booth | 170 lawmakers call for Pruitt to resign MORE (R-Texas), the No. 2 Senate Republican, said last month.

Separately, moderates had also objected to the Medicaid cuts in the initial Senate bill. The language ended funds for ObamaCare’s Medicaid expansion in 2024 and imposed a lower cap on Medicaid spending starting in 2025.

Those cuts remain in the newer version of the bill, though the new measure does add $45 billion in additional funding for opioid abuse treatment.

Moderates such as Sen. Shelley Moore CapitoShelley Wellons Moore CapitoFamily, friends mourn death of Barbara Bush Lawmakers propose boosting park funding with oil money Lawmakers trade barbs, torch Trump at DC soiree MORE (R-W.Va.) had previously said that opioid funding was not enough to win their support for the bill and that they needed Medicaid changes as well. 

“More opioid funding would be very good and very beneficial, but the core for me is the Medicaid provision,” Capito said last month. 

Capito says she is reviewing the latest bill and waiting for the CBO analysis.

Other senators have taken even stronger positions in defense of ObamaCare’s Medicaid expansion.

"You have to protect Medicaid expansion states. That’s what I want," Sen. Dean HellerDean Arthur HellerSenate GOP wary of new tax cut sequel GOP Senate hopefuls race to catch up with Dems Family, friends mourn death of Barbara Bush MORE (R-Nev.) said at a press conference last month announcing his opposition to the original bill in strong terms.

Sen. Lisa MurkowskiLisa Ann MurkowskiSenators press administration on mental health parity Overnight Energy: Watchdogs unveil findings on EPA, Interior controversies | GAO says EPA violated law with soundproof booth | IG says Zinke could have avoided charter flight | GOP chair probes Pruitt's four email addresses GOP fractures over push to protect Russia probe MORE (R-Alaska), who is also still reviewing the bill, likewise said last month that, “my position on Medicaid expansion and my support for it hasn’t changed.”

Some of the moderates have suggested their concerns with the Cruz amendment have been eased by the fact that the language does not repeal ObamaCare’s requirement that there be a single “risk pool,” helping prevent the market from splitting in two — one for healthy people in cheaper plans, and one for sick people in expensive plans.

“There are some other issues but there is an attempt at a single risk pool,” Cassidy said of the Cruz amendment on Thursday. 

However, experts dispute that there would, in practice, be a single market if the amendment became law. 

Sabrina Corlette, a professor at Georgetown University’s Health Policy Institute, said the requirement for a single risk pool is an “illusory requirement,” and that in effect, sick people would be in a separate pool and “have to pay a heck of a lot more.”

Joe Antos, a healthcare expert at the right-leaning American Enterprise Institute, agreed that the market would in effect be split into healthy and sick pools under the amendment, and argued that there is not enough money in the bill to make coverage affordable for people left in the sick pool, where the plans still comply with the ObamaCare regulations.

“You have to pour a lot more money into the compliant plans to make this work,” Antos said.

It is possible that more moderates will announce their opposition after reviewing the bill, though they will be under intense pressure from leaders to support it.

“It's 172 pages, guys,” Heller told reporters on the way to his car on Thursday. “So I've got a weekend of reading.”