Five changes GOP might make to healthcare bill

Senate Republican leaders are laboring to secure 51 votes for an ObamaCare replacement bill after being forced to delay the legislation until after the Fourth of July recess.

Leaders likely sent some updated proposals to the Congressional Budget Office for analysis before leaving town, but Senate Republicans have yet to lock in a new agreement.

Every tweak would have consequences, but here are five changes that could be made to the Better Care Reconciliation Act.

Keeping a tax on high earners

GOP senators are openly debating whether to keep a tax on high earners that was created to help pay for ObamaCare.

{mosads}The legislation that Republicans initially unveiled last week would have repealed a 3.8 percent tax on net investment income for individuals making more than $250,000 a year.  

Democrats slammed the proposal as a tax cut for the wealthy, and since then, several GOP senators have expressed a willingness to keep the tax to help pay for more generous coverage subsidies.

Keeping the tax could defuse the attacks from Democrats and win support from Republican moderates, though it could also spark a backlash from some conservatives who want all of ObamaCare repealed. 

Boosting subsidies

If the investment tax is kept, the savings will likely be used to provide larger subsidies to help low-income people afford health insurance. 

Senate GOP leaders could double the amount of money in the bill’s long-term state innovation fund if the tax is not repealed. The legislation, as currently drafted, dedicates $62 billion over eight years to encourage low-income people with high healthcare costs to buy insurance. Adding money to the fund could address concerns from a variety of moderates that the bill’s tax credits are not generous enough to help low-income people buy insurance.

Some Republican senators have balked at providing a tax cut for the wealthy without bringing down premiums and are looking for ways to address it. Under the draft Senate bill, people using subsidies to get insurance would either have to pay more in premiums to keep the plan they have now or have a higher deductible to keep their premiums in line.

“We [want to] address the issue of ensuring lower-income citizens are in a position to buy plans that are actually provide them appropriate healthcare,” Sen. Bob Corker (R-Tenn.) said last week. 

The Cruz amendment 

Sen. Ted Cruz (R-Texas) is pitching an amendment that would allow insurers to sell plans that don’t comply with ObamaCare regulations, so long as they also sell plans that comply with those rules. Cruz says his “Consumer Freedom Amendment” would lower premiums by giving insurers a path around the regulations. 

Experts are concerned that the amendment would undermine the individual market by allowing insurers to sell plans that might not have all of ObamaCare’s protections for pre-existing conditions. 

But the amendment has been endorsed by the White House and is supported by conservatives inside and outside of Congress. 

“We hope it’s part of the process of bringing everybody together,” White House legislative affairs director Marc Short said on “Fox News Sunday.” 

McConnell reportedly sent the CBO one list of proposals that included the Cruz amendment and one that didn’t. That underscores just how divisive the proposal is within the Republican conference. Pre-existing conditions are a political minefield, and some senators don’t want to remove any of ObamaCare’s protections.   

More opioid money

McConnell last week added to the bill $45 billion in additional funding to combat the opioid crisis, a move meant to entice moderate Sens. Rob Portman (R-Ohio) and Shelley Moore Capito (R-W.Va.).

Ohio and West Virginia have been ravaged by the abuse of prescription opioids and heroin, and the initial version of the bill only provided $2 billion in state grants to address the crisis. McConnell hoped that the two moderate holdouts would be convinced to vote yes if the grants were more generous.

But both Portman and Capito said that their concerns extend beyond opioid money to the deep cuts the original legislation would make to Medicaid. The CBO found the Senate bill would cut $772 billion from Medicaid and would result in 15 million people on Medicaid losing their coverage. 

Ohio Gov. John Kasich (R) last week said he warned Portman not to be swayed by the additional opioid funding, because $45 billion wouldn’t come close to overcoming the damage caused by the Medicaid cuts in the bill.

“That’s like spitting in the ocean,” Kasich said.

Medicaid changes

Centrist GOP senators have balked at the proposed Medicaid changes in the bill, and they’re backed up by their home-state governors, who accepted federal funding under ObamaCare to extend Medicaid coverage to millions of additional people.

Winning over the GOP centrists, including Portman, Capito, Susan Collins (Maine) and Dean Heller (Nev.), would almost certainly mean making significant changes to the Senate bill’s rollback of Medicaid. But doing so would likely generate opposition from Senate conservatives.

Senators also disagree on how to calculate spending on the Medicaid program.

The Senate bill institutes a per person cap on Medicaid funding for each state, adjusted annually for general inflation. But medical costs rise faster than other sectors, so experts warn that this would lead to Medicaid becoming drastically underfunded over time. It’s possible the formula will be changed to reflect medical inflation, but without other revisions, it likely won’t be enough to win over moderates. 

Conservatives have said they’re open to making a deal on Medicaid, but only if the Cruz amendment or a similar policy is added. 

An aide to Sen. Mike Lee (R-Utah) said the senator may be open to Medicaid changes “if Americans were given more relief from ObamaCare’s Title I regulations,” which are ObamaCare’s insurance rules.