Senate Majority Leader Mitch McConnell, R-Ky., has his work cut out for him over the next week if he's going to somehow move the health reform plan unveiled Thursday, June 22 through the Senate.
With virtually no chance of Democratic support, McConnell can lose only two votes from his party, which would leave the chamber deadlocked 50-50, and require Vice President Mike Pence to break the tie in favor of passage.
Gains in healthcare stocks were seen across the board in light of Thursday's news, with the Nasdaq Biotech Index rising 1%.
A bloc of the most conservative GOP Senators, Rand Paul of Kentucky, Ted Cruz of Texas, Mike Lee of Utah, and Ron Johnson of Wisconsin, are the main deterrents to moving the new legislation, though they all remain open to negotiations.They say its doesn't come close enough to repealing Obamacare. Their preference is to eliminate the federally subsidized insurance exchanges and its expansion of Medicaid but a move to far to the right risks losing more moderate Republicans.
Enactment of the Senate plan would cause a rise in the uninsured and end Medicaid expansion in 2024, compared to the 2120 phase out in the House bill passed in May. Over time, however, Medicaid cuts will be even deeper than the $800 billion the House bill cuts.
Despite the conservatives' reservations, Sheryl Skolnick of Mizuho Securities predicted the Senate bill will ultimately pass. "The conservatives can tout bigger Medicaid cuts and the moderates will like the near-term preservation and the subsidy and preexisting condition fixes," she said in a note Thursday.
That sentiment was shared by Beth Halpern, a partner in the healthcare practice of Hogan Lovells US LLP, who noted that the House version of Obamacare repeal faced similar opposition from conservatives before ultimately passing.
"House went through a long period of discussion, but showed what can be done to bring people on board," she said.
Many tenets of the Affordable Care Act have been re-worked or completely eliminated within the Senate's new healthcare bill. Say goodbye to funding for Planned Parenthood, individual mandates, and cost-sharing subsidies.
The women's health organization will be stripped of Medicaid funding for one year. Penalties for not having insurance would also disappear. Insurance subsidies will be scaled back, but will not be linked to age as seen in the House bill.
One of the biggest changes arises with Medicaid. Under Obamacare, states are encouraged to expand their Medicaid practices and received substantial funding to help expand coverage. The Senate bill will reverse course beginning in 2021, where it will steadily roll back enhanced federal funding over the course of three years. The House's version intended to start the rollback in 2020.
The modalities of Medicaid funding are also delivered into the hands of individual states. Compared with the House of Representatives version, the Senate cuts deeper into Medicaid funding cuts. Before, the federal government issued open-end funding, but now, states will receive a predetermined amount per person enrolled in Medicaid.
The ban on discriminating against those with a preexisting health condition will stay in place, but it does give states more flexibility to use "1332 waivers" to decide which coverage plans in their jurisdiction offer. Some have questioned whether this could weaken the protection for those with pre-existing conditions, such as with basic benefit packages.
The Senate will also address the opioid crisis by providing $2 billion to states, an aspect that is attractive to Senator Portman of Ohio, one of the moderate senators thought be on the fence regarding support for the plan.