Five changes the Senate could make to the ObamaCare repeal bill

GOP senators are making it crystal clear. The House’s ObamaCare repeal-and-replace bill is getting changed.

Senators say the legislation can’t pass the upper chamber in its current form, and they are looking to put their own stamp on the bill.

Here are five big changes that senators will be eyeing.

Tax credits

The Senate is likely to change the bill to provide more tax credits to better help low-income people afford health insurance.

Sen. John ThuneJohn Randolph ThuneWant to improve health care? Get Americans off of their couches More Dems want focus on job creation than wage growth Google, Apple, Amazon execs to testify at Senate privacy hearing this month MORE (S.D.), the No. 3 Senate Republican, is already working on an amendment to ramp up the credits.

The issue was also raised Thursday during a meeting in Senate Majority Leader Mitch McConnellAddison (Mitch) Mitchell McConnellKey GOP senators appear cool to Kavanaugh accuser's demand Trump hints at new executive action on immigration, wants filibuster-proof Senate majority The Hill's Morning Report — Sponsored by United Against Nuclear Iran — The Hill interviews President Trump MORE’s (R-Ky.) office that was focused on possible changes to the bill.

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Sen. John BarrassoJohn Anthony BarrassoTrump privately calls Mattis ‘Moderate Dog’: report Push to change wildlife act sparks lobbying blitz House and Senate negotiators reach agreement on water infrastructure bill MORE (R-Wyo.), part of the leadership team, acknowledged afterwards that changes to tax credits were “part of the active discussion.”

Under the House bill, a single 64-year-old making $26,500 would have to pay more than half his or her salary — $14, 600 per year — in premiums, according to the nonpartisan Congressional Budget Office. This stark datapoint made the rounds on social media after CBO scored the bill in March.

In part, this is because insurers can only charge older adults three times more than those who are younger and generally healthier under the Affordable Care Act. The House bill lets carriers charge older adults five times as much as young people. Also, tax credits are more generous for those with lower incomes under ObamaCare, and thus, lower premiums. 

Medicaid

Medicaid has emerged as one of the thorniest issues of the ObamaCare repeal and replace debate.

ObamaCare allowed states to expand the healthcare program for low-income and disabled people. Washington, D.C. and 31 states have taken the federal help, according to the Kaiser Family Foundation. This has provided coverage to an estimated 9.6 million people, according to the American Action Forum.

The House bill would undo that expansion in 2020.

Lawmakers from expansion states don’t want to see their constituents lose coverage. Lawmakers from states that didn’t expand don’t want to be penalized for staying true to their conservative principles.

“We need to get a balance to make sure that states are treated fairly,” Barrasso told The Hill.

After the House passed its bill, Sens. Rob PortmanRobert (Rob) Jones PortmanGraham calls handling of Kavanaugh allegations 'a drive-by shooting' Overnight Health Care: Senators target surprise medical bills | Group looks to allow Medicaid funds for substance abuse programs | FDA launches anti-vaping campaign for teens Bipartisan group wants to lift Medicaid restriction on substance abuse treatment MORE (R-Ohio) and Dean HellerDean Arthur HellerElection Countdown: Trump confident about midterms in Hill.TV interview | Kavanaugh controversy tests candidates | Sanders, Warren ponder if both can run | Super PACs spending big | Two states open general election voting Friday | Latest Senate polls Trump to fundraise for Heller, Tarkanian in Nevada The Hill's Morning Report — Sponsored by United Against Nuclear Iran — Kavanaugh and his accuser will testify publicly MORE (R-Nev.) quickly said they couldn’t support the current version of the measure, citing Medicaid as a major concern.

One option for the Senate would be to delay the House bill’s plan to eliminate the expansion in 2020. States can no longer choose to expand after 2020, and the federal government will cut off enhanced federal funding that same year.

“They’re at least going to push out the date that it phases out maybe further,” said Joe Antos, a resident scholar at the conservative-leaning American Enterprise Institute.

This would be easier than doing away with the provision altogether, as it would not greatly raise the cost of the bill, Antos said.

“It’s that age-old gimmick that Congress always does when there’s something that’s unpleasant, they push it way out,” Antos said.  

Coverage

About 24 million more people could be without health coverage by 2026 under the House’s bill, according to a March CBO analysis.

The House passed its latest bill before CBO could finish a new analysis.

This could be a big problem in the Senate, where a number of Republicans are worried about passing a measure that could leave more people in their states uninsured.

“That's not what President Trump promised,” Sen. Bill Cassidy (R-La.) told CNN in March. “That's not what Republicans ran on.”

The issue of ensuring people retain coverage was an important one in the House debate, but it is likely to be even more intense for senators representing entire states, not smaller districts.

Pre-existing conditions

Cassidy calls it the “Jimmy Kimmel test.”

The talk show host gave an impassioned speech this week on his show, tearfully explaining how his child was born with a heart defect. In a video that went viral, Kimmel made the case for why people with pre-existing conditions should have health coverage.

Cassidy suggested a new litmus test for a Senate bill.

“I ask, does it pass the Jimmy Kimmel test?,” Cassidy told CNN. “Will a child born with congenital heart disease be able to get everything she or he would need in the first year of life? I want it to pass the Jimmy Kimmel test.”

Cassidy was answering a direct question about whether he would support a bill that imposed caps on the amount of money an insurer would have to spend on a policy, but the meaning of his remarks appeared broader.

He and other Republicans will want a bill that definitively ensures people who pre-existing conditions will not be left without coverage.

A key amendment in the House backed by Reps. Tom MacArthur (R-N.J.) and Mark Meadows (R-N.C.) lets states opt out of a core ObamaCare requirement called community rating, which prohibits insurers from charging sicker patients more money.

Critics of the House bill insist this will lead to higher costs or less coverage for those with pre-existing health conditions.

“We cannot pull the rug out from under states like Nevada that expanded Medicaid and we need assurances that people with pre-existing conditions will be protected,” Sen. Dean Heller (R-Nev.), one of the most vulnerable senators in 2018, said in a statement.

Essential health benefits

ObamaCare requires insurers cover a list of services, such as maternity care and substance abuse and mental health treatment.

The MacArthur amendment lets states opt of this mandate, and it’s unclear if this will fly in the upper chamber.

The Senate parliamentarian has control over the strict parameters of what can be in a reconciliation bill, the fast-track budget maneuver Republicans are using to repeal and replace ObamaCare because it only requires 51 votes to pass.

“I do think that the language of the MacArthur amendment allowing waivers from the essential health benefits and community ratings rules is definitely something that is going to be challenged under the Byrd rule and is definitely vulnerable,” Ed Lorenzen, senior adviser for the Committee for a Responsible Federal Budget, said.

He cautioned, though, that it’s hard to know for sure how the Senate parliamentarian will rule.

Jessie Hellman contributed.