President Donald Trump sat at health insurance policy lunch today between Dean Heller, a Republican who opposes the Better Care bill, and Timothy Scott, who supports the bill. (Photo: White House)

Senate Majority Leader Mitch McConnell said today in Washington that the Senate will definitely vote next week on a motion to proceed with debate on the Better Care Reconciliation Act bill.

“Next week, we’ll get on the bill,” McConnell said at a press conference that was streamed live on C-SPAN’s website. “I have every expectation that we’ll be able to get on the bill.”

(Related: 5 Better Care Bill Revision Highlights for Agents)

If the Senate approves the motion, the Senate would consider the bill under budget reconciliation rules. Budget reconciliation rules would give each senator a chance to propose amendments to the bill, McConnell said.

McConnell said the Senate would start by considering two main alternatives: voting on something like the version of the Better Care act bill that was unveiled earlier this month, or voting on an amendment that would create a completely new version of the bill. The “amendment in the nature of a substitute” would simply repeal many Affordable Care Act revenue and spending provisions, with a two-year delay before the changes would take effect.

“It’s pretty obvious we’ve had difficulty getting 50 votes to proceed,” McConnell said.

McConnell said proceeding with debate would give senators who have concerns about the Better Care bill an opportunity to improve it.

The McConnell Amendment

The proposed McConnell amendment would create a stripped-down version of the Better Care bill. The amendment would immediately:

  • Eliminate the individual coverage mandate and employer coverage offer mandate.

  • Increase funding for community health centers and state substance abuse program grants.

Starting in 2020, the McConnell amendment would:

  • Repeal the Affordable Care Act Medicaid expansion program.

  • Repeal individual health insurance premium subsidies.

  • Repeal many of the Affordable Care Act tax provisions.

  • End extra federal support for a program that provides personal care services for people with severe disabilities.

The amendment would also push the start date for the Cadillac plan excise tax on high-cost health plans back to 2026.

CBO

The Congressional Budget Office (CBO) has estimated in the past that the Senate’s Better Care bill and the House health insurance bill, the American Health Care bill, would lead to the United States having about 22 million more uninsured people in 2026 than it would have if the current Affordable Care Act system stays in place and works as expected.

In a new forecast released today, the CBO predicts that, by 2026, the McConnell amendment could increase the number of uninsured people by about 32 million when compared with how many people might be uninsured if the current rules stay in effect.

The McConnell amendment could lead average individual major medical premiums to be about twice as high in 2026 as they would be under the current rules, according to the CBO analysts.

Adopting the McConnell amendment could increase premiums about 25% in 2018, the CBO says.

The CBO has posted a copy of the analysis here.

Budget Measures v. Full Repeal

Republicans have 52 seats in the Senate. Vice President Mike Pence presides over the Senate and can cast a vote to break a tie.

Under traditional Senate rules, supporters of budget reconciliation bill, with provisions that the Senate parliamentarian classifies as germane to the federal budget, need just 51 votes to get to a vote on the Senate floor.

Supporters of an ordinary bill need 60 votes to have a bill come up for a vote on the Senate floor.

(Video: White House)

Because of the Senate budget reconciliation process rules, the American Health Care bill, the Better Care bill and the McConnell amendment would leave much of the Affordable Care Act in place. The parts that would stay the same have no obvious relationship with the federal budget. Some provisions that are in the bills, however, have little obvious connection with the federal budget.

It’s still possible that the Senate parliamentarian could still rule some bill provisions as being out of bounds.

If that happens, it’s not clear whether Senate Republicans would stick with the traditional Senate budget reconciliation rules.

It’s possible that Senate Republicans could find a way to get around the rules, change the rules, or ignore the rules.

Even if the Senate ended up rejecting any efforts to change the Affordable Care Act, it’s possible that the Trump administration officials could simply change the health system rules the way they want to change the rules and dare critics to try to stop them.

Lunch at the White House

President Donald Trump worked to rally Republican Senate support for changing or repealing the Affordable Care Act at a luncheon at the White House.

Trump sat between Sen. Dean Heller, R-Nevada, one of a number of Republicans who appear to be opposed to the current version of the Better Care bill, and Sen. Tim Scott-R-S.C., who supports the bill.

Some were speculating Tuesday that the Trump administration might be getting ready to withhold Affordable Care Act cost-sharing reduction subsidy payments to insurers Thursday. The subsidy program helps reduce deductible and coinsurance costs for low-income people who have Affordable Care Act public exchange plan coverage and high medical bills.

The White House posted a video of Trump’s luncheon address. During the address, Trump did not threaten to withhold the payments, but he appeared to allude to the possibility that the subsidy payment stream would stop.

“Being fine with Obamacare isn’t an option, because it’s gone,” Trump said. “The insurance companies are fleeing.”

The system appears to be working now because the federal government is spending hundreds of millions of dollars each month on subsidies for the system, Trump said.

“When the payments stop, it stops immediately,” Trump said.

Trump also criticized the Democrats for failing to provide proposals of their own. Democrats are failing to offer ways to improve the current system because what they really want to do is move to a single-payer health care system, he said.

Trump made a point of teasing Heller for his lack of support for the Better Care bill.

“You weren’t there, but you’re going to be,” Trump said to Heller. Trump then looked at the other senators and said, ”Look, he wants to remain a senator, doesn’t he?”

Trump looked back to Heller. “I think the people of your state, which I know very well, they’re going to appreciate what you hopefully will do. Any senator who votes against starting debate is really telling American that you’re fine with Obamacare.”

Read McConnell’s New Affordable Care Act Repeal Lacks GOP Votes to Pass on ThinkAdvisor.