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What's Going on With the Senate's Health-Care Bill?

The Senate is expected to take its first steps toward ACA repeal and replace.
Senator John McCain.

Senator John McCain.

After weeks of negotiations and drama, the Senate is expected to vote today on a procedural motion to proceed to debate Affordable Care Act repeal-and-replace legislation (not on the legislation itself). The outcome of the procedural motion is far from certain—last week, a number of Republican senators said they would not vote for a motion to proceed to debate the latest version of the Senate's Better Care Reconciliation Act or the "clean repeal" bill that conservatives want, which seemed to doom the Senate's repeal-and-replace efforts.

In the interim, the White House and Senate leadership have continued to both apply pressure to hold-outs and to refine their strategy, while Senate Majority Leader Mitch McConnell (R-Kentucky) has maintained that he will hold a vote on a motion to proceed to debate on something, even if the vote was destined to fail. What that "something" is exactly has been a topic of confusion. Republican senators have, until today, said they have no idea if they're being asked to proceed to debate on the BCRA, a clean repeal bill, or something else entirely.

This morning, according to reporting from numerous outlets, Senate leadership finally laid out what will happen if the motion to proceed succeeds. After the 20 hours of debate permitted under the rules of reconciliation, McConnell will first call for a vote on the "clean repeal" bill that passed in 2015 (that vote is expected to fail); he will next call for a vote on a version of the BCRA which includes both Senator Ted Cruz's Consumer Freedom Amendment and additional Medicaid funding (this vote is also expected to fail, since it has not been scored by the Congressional Budget Office and would require 60 votes to pass). The end-game, however, and the legislation that Senate leadership is hoping to actually pass, will be a "skinny repeal" bill that leaves almost all of the ACA in place, with the exception of the individual and employer mandates and the medical device tax. This skinny bill would essentially serve as a legislative shell that would allow House of Representatives and Senate negotiators to work out more complete repeal-and-replace legislation in conference. (The bill created in conference would then have to be approved once again by the House and Senate.)

This skinny bill would essentially serve as a legislative shell that would allow House and Senate negotiators to work out more complete repeal-and-replace legislation in conference.

As Larry Levitt of the Kaiser Family Foundation points out, the CBO actually scored a similar "skinny repeal" bill in 2015. The version scored repealed the mandates, the medical device tax, and the tax on so-called "Cadillac" insurance plans. The CBO concluded that such a repeal bill would reduce the number of Americans "with health insurance coverage by about 14 million to 15 million in most years (about 20 percent of those are estimated to be children)." The CBO also predicts that repealing the individual mandate would also increase premiums—by about 20 percent—in the non-group markets as young and healthy people chose to forgo health insurance coverage. While people who receive federal subsidies to purchase health insurance would be protected against those premium increases, those making more than 400 percent of the poverty line would see markedly higher premiums. The final legislation worked out in conference would likely be quite different from the shell passed in the Senate or the skinny repeal scored by the CBO in 2015. Some policy experts (although not all) also believe that repealing the individual mandate would result in insurers immediately exiting the non-group markets.

The procedural vote is expected to occur around 2:15 EST, and it will be close. John McCain (R-Arizona), who is fighting brain cancer, flew back for the vote, and Senator Rand Paul (R-Kentucky), who was previously opposed to the motion to proceed, announced this morning he would vote to proceed. A number of Republican senators, however, reportedly remain undecided.