July 27th was a rollercoaster ride for observers of the final day of debate in the Senate on various bills that would repeal and/or replace the Affordable Care Act (ACA). Two earlier drafts of health care reform, the Better Care Reconciliation Act (BCRA) and the Obamacare Repeal Reconciliation Act (ORRA), were rejected. Late into the night, the final version offered, a "skinny" repeal of the ACA, was voted down with three Republican Senators (John McCain (AZ), Lisa Murkowski (AK) and Susan Collins (ME)) siding with Democrats to reject the measure. Here's how the process played out:
Motion to Proceed: On Tuesday, the Senate narrowly passed a motion to proceed to floor debate. Two Senators (Collins and Murkowski) voted against, leaving the final vote 50-50, necessitating Vice President Mike Pence to break the tie in favor of proceeding. Senator John McCain, who was recently diagnosed with brain cancer, flew in for the vote. After making an impassioned speech about the need for a bipartisan process, he sided with Republican leadership to advance the motion.
BCRA: Late Tuesday, the Senate first considered the Better Care Reconciliation Act (BCRA), including the Cruz/Lee amendment which would allow for the sale of scaled-down insurance plans. The amendment failed with a vote of 43-57, with Republicans Collins, Graham, Paul, Corker, Heller, Moran, Murkowski, Cotton and Lee voting no. Because the amendment had not been scored by the Congressional budget office, the measure would have needed 60 votes to pass.
ORRA: On Wednesday, the Senate voted down the Obamacare Repeal Reconciliation Act (ORRA), which was the closest version of any bill to a straight repeal of the ACA with a two year delay. It would have removed Medicaid expansion, individual and employer mandates, marketplace subsidies, marketplace exchanges, and most ACA taxes. The version the Senate voted on included an amendment by Rand Paul (R-KY) that would have banned people from using subsidies to purchase plans that cover abortion. This measure failed 45-55, with Republican Senators Alexander, Capito, Collins, Heller, McCain, Murkowski, and Portman voting no. This measure would have needed 50 votes to pass.
Return to Regular Process: On Wednesday, Democratic Senator Joe Donnelly (IN) offered an amendment that would return the process of voting on this bill to the Senate Finance Committee, rather than going through the budget reconciliation process. Notably, the amendment also would have removed all Medicaid provisions from the bill. This vote failed, along straight party lines, with all Democrats voting for and all Republicans voting against, leaving the final vote at 48-52. This amendment would have required 50 votes.
"Skinny" Repeal: The final measure voted on in the early morning hours of July 28 was the "skinny" repeal, so called because it would have repealed the ACA's individual and employer mandates, and the tax on medical device companies, but would have left intact most other taxes, the Medicaid expansion, subsidies, and preexisting conditions. Prior to the vote, pressure was on for Republicans to vote on the bill in order to get it into conference with the House. Senators McCain, Graham, Johnson, and Cassidy held a press conference saying they would vote in favor of the measure if and only if they received adequate assurance from Speaker of the House Paul Ryan that the bill would go through the conferencing process and change the final text (instead of having the House take up the measure as written). Initially Ryan had said the House might just vote on whatever the Senate passed, but later changed his position and said that he would allow the bill to go to conference. Despite this, McCain ultimately voted against the measure, joining Senators Collins and Murkowski in voting no, which defeated the measure. The final vote was 49-51, and it would have required 50 votes to pass.
What's Next? The Senate will reconvene next week, having delayed the August recess. It is unclear what the next move will be in the health care reform arena. Many lawmakers are hopeful that their colleagues will take Senator McCain's words from Tuesday extolling bipartisanship to heart and will work in an open, collaborative process to address issues on the horizon - including CHIP reauthorization and stabilizing insurance markets. Medicaid reform should not be considered off the table in whatever policy conversations come up next. ANCOR is extraordinarily grateful for the tremendous advocacy efforts undertaken by providers that helped to defeat this most recent attack on Medicaid.
Meanwhile in the House: While all eyes were on the Senate, the House passed a spending package, the "Make America Secure Appropriations Act", a minibus of four out of the twelve spending bills needed to fund the government past September 30. The bill includes $789 billion in defense spending, funding the Pentagon, veterans benefits and nuclear programs, and also earmarking funds to start building a border wall along the U.S.-Mexico border. Although House members had been notified prior to the vote that they should be "on call" in case they needed to come into session to vote on a Senate-passed health care bill, the House went into recess after passing the appropriations bill.