As of Thursday night, two Republicans—Sens. Rand Paul (R-Ky.) and Susan Collins (R-Maine)—had said they would vote against a motion to proceed with the revised Better Care Reconciliation Act (BCRA), meaning Senate Majority Leader Mitch McConnell (R-Ky.) cannot afford to lose any more votes.
Collins said she remained opposed to the bill's Medicaid cuts. "The only way I'd change my mind is if there's something in the new bill that wasn't discussed or that I didn't fully understand, or the (Congressional Budget Office [CBO]) estimate comes out and says they fixed the Medicaid cuts, which I don't think that's going to happen," she said Thursday after a briefing on the bill.
In an appearance Thursday on Fox News, Paul said he would not support the revised BCRA, noting that it remains too close to the original bill, which he had said did not go far enough to repeal the ACA.
Sen. Shelley Moore Capito (R-W. Va.) in a statement said, "I still have concerns" about the proposed Medicaid cuts, but said she would remain undecided until a final CBO score is released.
Several other GOP senators, including Sen. Dean Heller (R-Nev.), have said they are undecided on the bill and need more time to review the bill's language. A group of moderate Republican senators met Thursday with McConnell to discuss further changes. According to The Hill, those lawmakers are seeking changes that would increase funding for states and increase clarity on how an additional $70 billion for state-based initiatives would help lower-income individuals purchase coverage.
The latest version of the bill won support from conservative GOP Sens. Ted Cruz (Texas) and Marco Rubio (Florida), both of whom opposed the bill in its original form. According to Politico, Cruz said he would support the bill if the Cruz said if language allowing insurers who sell ACA compliant plans to also sell non-compliant ACA plans remains in place.
However, Sen. Mike Lee (R-Utah), who worked with Cruz on the proposal that would give insurers the ability to sell non-ACA compliant plans, said he is concerned about changes GOP Senate leaders made to the initial proposal and how they could affect premiums. He said it was "unclear" whether the revised version is better than the previous version.
Meanwhile, Sens. Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.) on Thursday floated an alternative proposal that would maintain most of the ACA's taxes and direct that money back to states. A GOP aide said the bill would likely be offered as an amendment to the BCRA next week to test its support, Politico reports.
According to Politico, CBO is expected to release a new score of the Senate's bill on Monday, though it is unclear if that score will include Cruz's modified amendment. If the amendment is not included in CBO's score, it could take days or weeks before CBO provides a final score, which traditionally has been required before the Senate can move to a vote.
However, Kaiser Health News reports that some Senate Republicans on Thursday floated the idea of asking HHS, rather than CBO, to score the bill—which could potentially allow a vote to occur sooner. Democrats quickly denounced that idea as partisan since HHS is run by a Trump administration appointee.
Sen. Lamar Alexander (R-Tenn.) said McConnell on Tuesday plans to hold a vote on the motion to proceed to the bill. McConnell also said the Senate "will be voting next week," and according to Politico he is urging Republicans to vote yes on the motion to proceed, saying that they will have opportunities to amend the bill after it reaches the floor.
President Trump on Thursday remained optimistic that the Senate will strike a deal. He told reported on board Air Force One, "I think we're going to have something that's really good and that people are going to like" (Hellman, The Hill, 7/13; Bolton, The Hill, 7/13; Sullivan, The Hill, 7/13; Bolton, The Hill, 7/14; Daugherty, McClatchy/Sacramento Bee, 7/13; Everett/Haberkorn, Politico, 7/13; Werner/Fram, AP/Sacramento Bee, 7/13; Armour/Peterson, Wall Street Journal, 7/13; Rovner, Kaiser Health News, 7/13; Everett, Politico, 7/13; Limitone, Fox News, 7/13).
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No matter the outcome of the debate over the future of the Affordable Care Act and Medicaid, the likely renewed focus on delivery system costs will make further clinical efficiency an imperative.
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