What we know so far about what’s in the secret Senate health bill

The secret Senate negotiations to repeal and replace Obamacare are getting closer to a bill that would unwind the law’s Medicaid expansion and roll back some of its insurance regulations.

The Senate bill will likely resemble the overwhelmingly unpopular House bill in many important ways. The House bill fundamentally overhauled Medicaid, the nation’s largest insurer, and diluted Obamacare’s financial assistance for people who buy private coverage. It unwound some of the law’s insurance protections for people with preexisting medical conditions and defunded Planned Parenthood. A Congressional Budget Office estimate found the House bill would lead to 23 million fewer Americans having health insurance by 2026 and amounted to a $830 billion cut from Medicaid.

Senators want to soften some of those provisions — but not eliminate them entirely. This is still a plan that would likely lead to millions fewer Americans being covered, overhaul Medicaid, and undo some of the law’s insurance protections.

Many of the details haven’t been resolved yet or at least aren’t public. Senate Majority Leader Mitch McConnell has elected to entirely forgo the usual legislative process — no public hearings and no expert testimony. And the talks to work out differences between the centrist and conservative wings of the Senate GOP conference are going on behind closed doors.

But McConnell appears to be making a play to win over the moderate members of his caucus. The changes might be enough, politically, to clear the Senate. McConnell needs 50 of the 52 Senate Republicans to back the bill.

“I’m obviously opposed to the House bill and it’s clear from the outline that I have seen of the Senate’s — where there were a lot of question marks, so they’ll be filled in — it’s quite different from the House bill and I think that’s a good thing,” said Sen. Susan Collins (R-ME), a crucial swing vote, on Wednesday.

The Senate plan looks like it will eventually end Obamacare’s Medicaid expansion and fundamentally overhaul the Medicaid program’s financing. The House bill, which made similar changes, had been estimated to lead to 14 million fewer people enrolled in the program in 2026, compared to what would be expected under Obamacare, and an $830 billion spending cut.

Twenty Senate Republicans represent states that expanded Medicaid under Obamacare, covering millions of their poorest citizens. The House bill would have abruptly cut off the generous federal funding for Medicaid expansion in 2020; these senators have long said they want a more gradual phaseout of that money.

Now they are haggling over the details. McConnell has proposed phasing out the Medicaid expansion over three years, by gradually reducing the federal funding for those people. Senators preoccupied with Medicaid expansion, led by Ohio Sen. Rob Portman, have countered with a seven-year “glide path.”

A five-year phaseout would seem like the logical compromise.

“Who knows?” Portman said recently when asked about that obvious middle ground.

“We’re negotiating now. I’m still going for seven,” said Sen. Shelley Moore Capito (R-WV), one of the other senators most focused on Medicaid.

Whatever the length, though, the result would likely be the same, as Vox’s Sarah Kliff noted: The enhanced federal funding for Medicaid expansion would end at some point.

States could still choose to cover the Medicaid expansion population, but they would receive much less federal funding to do so. Some states that expanded Medicaid have also stipulated that they would end the expansion if the federal funding were reduced.

The House bill also overhauled the entire Medicaid program, which covers 70 million of the low-income, elderly, and disabled Americans. It would cap spending on the program, which is funded jointly by the states and the federal government, for the first time. States would receive a set amount of money from the feds for each person covered by Medicaid, and they would be responsible for any additional spending. That’s a fundamental change to Medicaid — it would no longer be an open-ended entitlement.

There are a lot of technical details that Senate Republicans are reevaluating. How much should the caps increase over time? How do you resolve the Medicaid spending disparities across states? Should you allow states to boost spending down the road, if they want to pay doctors and hospitals more?

But the fundamental proposal — capping federal Medicaid spending — looks likely to remain. The fate of other provisions in the House bill, such as allowing states to require Medicaid participants to work or look for work, are unknown for now.

The Senate plan could create financial assistance for private insurance that resembles the tax credits available under Obamacare — it would factor in a person’s income and possibly the state they live in — but could differ in an important way.

Obamacare’s financial aid limited people’s exposure to premium increases. Under the law, people have to pay a certain percentage of their income for insurance. The federal government picked up the rest if premiums went up substantially.

The GOP’s tax credits could end up being a flat dollar amount, as the House bill was, which means they would not adjust if premiums increased.

“That’s pretty fundamental to the Republican worldview that there shouldn’t be open-ended entitlements and that federal spending should be capped,” Larry Levitt at the Kaiser Family Foundation told me.

The House bill also ended Obamacare’s financial assistance for people to purchase private health insurance. Instead, aid would have been based almost entirely on age.

As numerous expert analyses pointed out, that change could lead to the poorest Americans receiving substantially less help than under Obamacare. That could make insurance unaffordable for them, a problem that is exacerbated by the rollback of the Medicaid expansion, which also covers lower-income Americans.

Capito, explaining her desire for a longer Medicaid expansion phaseout, said she wanted those people to transition “either to Medicaid, or to coverage that’s as good as the Medicaid coverage.”

So more generous financial aid could help achieve that. It’s something that Senate Republicans have long said they want to do and looks likely to be part of their plan.

Senators are also discussing whether to add back in a geographic variable to the assistance to provide more support in high-cost states. Alaska’s Republican senators, Lisa Murkowski and Dan Sullivan, are particularly focused on that issue.

“A high-cost state like ours, what the House proposed doesn’t help at all. In fact, it hurts, hurts, hurts,” Murkowski told me Thursday. “So you either have some recognition of high-cost and geographic issues, or it doesn’t work.”

I asked if that was a deal-breaking issue for her.

“You have not helped Alaskans,” she said.

Senate Republicans appear ready to roll back some of Obamacare’s insurance regulations. The health care law guaranteed nobody could be denied coverage, stopped insurers from charging sick people more than healthy people, limited how much more older people could be charged, and required plans to offer insurance that covered a comprehensive set of essential health benefits.

The Senate bill, like the House bill, could allow insurers to charge older people five times as much as younger people. Obamacare had limited that ratio to three times as much.

McConnell has proposed allowing the waivers from the essential health benefits requirement, as the House bill did. If states waive that rule, health insurers could craft plans that don’t cover certain expensive services, which could discourage sick people from signing up for their coverage.

But, unlike the House bill, the Senate plan could still prohibit plans from charging sick people more than healthy people.

That would allow senators to say that, by the letter of the law, they are keeping Obamacare’s protections for people with preexisting medical conditions. But waiving the essential health benefits rule increases the risk that sicker people would not be able to buy insurance that covers the services they need.

Like the House bill, the Senate plan would likely include additional funding to help those people afford insurance. But many experts, including the CBO, have said that the funding made available by the House would not fully offset the negative consequences of rolling back those regulations.

Some senators are pushing leadership to include new funding for programs that address the opioid crisis, fearful of what their plan could mean for people in recovery without additional money.

Senators like Capito and Portman have said part of their concern about the Medicaid cuts in particular is the effect on the opioid crisis, which is now killing more than 30,000 Americans every year. Medicaid is the single largest payer of mental health and addiction services in the country.

“I need assurances that those folks who are using Medicaid expansion for that coverage are going to be covered for that problem,” Capito said this week.

That group of senators has proposed spending $45 billion over 10 years on services specifically targeted to the opioid crisis. That figure was based on previous estimates that repealing Obamacare’s Medicaid expansion would reduce funding for substance abuse treatment by $4.5 billion per year.

The details of what that funding might do are not publicly available, though, because of the secretive nature of the negotiations.

It could follow the model of the 21st Century Cures Act, passed by Congress last year and signed by President Barack Obama. That money was directed to state programs focused on treatment and prevention efforts, rather than insurance programs like Medicaid.

The House bill defunded Planned Parenthood, cutting off $500 million in federal funding that the women’s health organization receives. Republicans have long opposed the group because it performs abortions, though federal dollars are already prohibited from paying for abortions.

That promised to be a problematic provision in the Senate, where key swing votes like Collins and Murkowski have previously said they don’t want to defund the group. It also remains possible that defunding Planned Parenthood doesn’t comply with the complex Senate rules that the Republicans are using to pass the legislation with a bare majority.

But if the provision does fit under the rules, even those senators most supportive of Planned Parenthood aren’t saying unequivocally right now that they would oppose the bill over defunding the organization.

“I would want an opportunity to strike any defunding,” Collins told reporters this week. That could mean taking a vote while the bill is being considered on the Senate floor to remove the Planned Parenthood provision.

But that’s not the same as saying she would vote against the final bill, if that vote to strike failed and the legislation still defunded the organization.

“I am against defunding Planned Parenthood,” Collins said. “But as I’ve said before, there are a lot of important issues.”