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A clear guide to what the hell is going on with the Senate health care bill

7 things you need to know.

Mark Wilson / Getty Images
Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

The twists in the Senate health care debate this week have been dramatic, unpredictable, and rapid-fire. Just a few days ago, it seemed like the whole plan had been put on hold.

But now Senate Republicans are frantically rushing ahead, hoping to put some kind of bill up for a vote early next week. It’s a mad dash to the finish line, the end of a six-month debate in Congress and a seven-year Republican promise to repeal Obamacare. As senators left town Thursday afternoon, no clear path forward had emerged.

This is the bottom line: Senate Republicans are promising a vote next week, but nobody is sure what they’re going to vote on. There are competing bills, one to repeal and replace Obamacare, one to partially repeal it but with no replacement. It’s not clear whether there are even the votes to start debate, because senators don’t know what is being put up for a vote.

Underscoring the absurdity of the week, Sen. Rand Paul (R-KY) floated to reporters — perhaps half jokingly — that Senate Republicans effectively draw the competing plans out of hat to decide the order that they’d be voted on.

“I think they’re pretty equal in support. Let’s do a random selection, let’s have three or four of them. Put them in random order on the first day, equal billing,” he said. “I think that’s a compromise.”

It’s been a busy, bewildering week. Here’s where things stand right now.

There are two bills in play — one to repeal Obamacare, one to replace it

One reason the debate has become so hard to follow: Senate Republicans are considering two health care bills right now.

One is the Better Care Reconciliation Act, the repeal-and-replacement plan that Republicans has been discussing and drafting in private for the past two months. That’s the health care bill you’ve been hearing about for most of the Senate debate.

The other is the Obamacare Repeal Reconciliation Act, an updated version of 2015 legislation that repeals all funding for Obamacare’s insurance expansion but keeps its regulations on insurers. It was released Wednesday.

Neither bill has the votes to pass. But the Senate is still trying.

Earlier this week, the Senate health care push seemed dead. Monday night, two more Republican senators came out against the current version of the BCRA, bringing the total to four, enough to block the bill. Then Senate Majority Leader Mitch McConnell said the Senate would instead vote soon on the repeal-only legislation.

But by midday Tuesday, three Senate Republicans said they would oppose the repeal bill, enough to stop that bill as well. McConnell said the Senate would vote soon nonetheless, perhaps just to bring the six-month health care saga to an end.

Then the White House intervened. President Trump told senators at the White House Wednesday to keep working on the BCRA. (Trump has been all over the place: He has endorsed repeal only, letting Obamacare fail, and repeal and replace this week alone.)

Vote counts haven’t changed for either bill. But Senate Republicans are still discussing the BCRA.

One bill would lead to 22 million fewer people with insurance. The other: 32 million.

The BCRA, the bill to repeal and replace Obamacare, would do a few big things:

  • It would scale back Obamacare’s financial assistance for people who buy private coverage.
  • Insurers could sell health plans that don’t comply with Obamacare’s insurance regulations — for example, they could charge people more based on preexisting conditions or offer insurance that doesn’t cover maternity care or hospitalization.
  • It would eventually end Obamacare’s Medicaid expansion and overhaul the entire Medicaid program by instituting a hard federal spending cap.
  • It provides about $200 billion to stabilize the insurance market, but experts have said that likely isn’t enough money to offset the negative effects.

The most recent version of the BCRA hasn’t yet been reviewed by the Congressional Budget Office. But the CBO found that the original version would lead to 22 million fewer Americans having health insurance in 2026, versus Obamacare, and out-of-pocket costs would rise dramatically. Medicaid spending would be cut by $772 billion over 10 years, versus current law, and 15 million fewer people would be enrolled in the program.

The ORRA, on the other hand, would repeal broad swaths of Obamacare and not replace any of it:

  • Tax subsidies for private coverage, Medicaid expansion, taxes on the wealthy and health care industry, and the law’s individual mandate would be repealed.
  • Obamacare’s insurance regulations would not be repealed, however, because the Senate can’t do that and bypass the possibility of a filibuster.
  • Repeal would happen in two years.

Republicans say they would craft a new replacement plan in the two years before repeal takes full effect, though experts warn that passing the bill would have immediate consequences for the insurance market.

Without a replacement, the CBO projected that the ORRA would lead to 32 million fewer Americans having health insurance in 2026, that insurance premiums would double over the next 10 years, and that most of the country would have no health plans available on the individual market.

The Senate is preparing to vote early next week. But they don’t know what they’re voting on.

Based on comments from Sens. John Cornyn (R-TX) and John Thune (R-SD), both members of Senate leadership, the plan is for Republicans to keep working on the BCRA, their plan to replace Obamacare, to see if they can strike a deal that gets 50 votes.

But if they can’t, then the Senate could instead take up ORRA.

Either way, the first vote is a procedural vote, not a vote on final passage, known as a “motion to proceed.” That starts the debate. It would need 50 votes.

Another possible compromise, as suggested by Paul, would be for Senate Republicans to agree that they will vote to open debate, and then the first two votes after that would be on ORRA and BCRA.

But leadership hasn’t decided yet what they’ll do.

John McCain’s newly diagnosed brain cancer will make it even harder for a bill to pass

Republicans are using a Senate process that prevents Democrats from filibustering, so they need only 50 votes to pass a bill. There are 52 Republicans in the Senate.

Right now, neither bill has the votes to pass. At least six senators — Susan Collins of Maine, Paul, Mike Lee of Utah, Jerry Moran of Kansas, Shelley Moore Capito of West Virginia, and Lisa Murkowski of Alaska — have said they’d oppose the most recent version of the BCRA.

At least four senators — Collins, Capito, Murkowski, and Rob Portman of Ohio — have said they would oppose the ORRA.

But after Sen. John McCain’s cancer diagnosis, there are effectively only 51 Republicans in the Senate for the foreseeable future. (It’s not clear how long McCain will be out.) That means two Republican “no” votes are enough to scuttle the plan.

Repeal and delay is almost certainly not going to pass

If Republicans end up voting on the repeal-only bill, ORRA, its chances of passing are slim to none. Too many Republicans simply refuse to vote for repealing Obamacare without replacing it.

The BCRA also has problems — namely, conservative and moderate senators want very different things — but it will be the focus of the discussions over the next few days. Something would likely have to change in the BCRA for any of the current holdouts to come around and support it.

Negotiations on a repeal-and-replace bill are ongoing

A large group of senators, including most of the holdouts, met in a Senate office building on Wednesday night to discuss a path forward. They didn’t say much as they came out of the meeting, so it’s unclear if much progress was made on the BCRA.

Medicaid has been a sticking point, particularly for a half-dozen senators who represent states that expanded the program under Obamacare. The Hill reported that Senate leaders are prepared to add $200 billion in funding to the bill for those states. That wouldn’t actually be enough to offset the $772 billion in Medicaid cuts, much of which results from ending the expansion, but maybe it would win their votes anyway.

Collins, the most moderate Senate Republican, might be unpersuadable no matter what. She is concerned about the Medicaid spending caps and the projected losses in insurance coverage. She told reporters she had not been invited to the meeting on Wednesday night.

The conservative holdouts are tricky too. Paul seems ungettable: He staked his opposition on the $182 billion in stabilization funding, calling it an insurance bailout, and leadership would never remove that money from the bill.

Lee is unsatisfied with the version of a proposal by Sen. Ted Cruz, allowing non-Obamacare plans back on the market. A technical change might win him over. Moran’s demands have been opaque throughout the debate.

Collins, Paul, and an absent McCain are enough to block the BCRA. That seems for now like an insurmountable math problem. But Republicans aren’t giving up yet. That’s the one thing we’ve learned from these wild past few days.