Will Senate Republicans Throw Medicaid Under the Bus?

It’s really happening. After the chaos of last week’s House vote, the American Health Care Act (AHCA) is headed to the Senate. Progressives accustomed to watching bills languish in the Senate due to the filibuster can’t afford to be complacent: thanks to budget reconciliation rules and Vice President Mike Pence’s role as tie-breaker, the AHCA only needs 50 votes to pass. In other words, it can pass even if every Democrat and two Republicans vote against it.

Despite the widespread criticism of the House’s absurdly secretive and rushed process, key senators are indicating that the Senate will also attempt to pass their bill without holding any public hearings or committee markups. The House’s process can’t lower the bar for the Senate: this lack of transparency and public debate is unprecedented for legislation of this scale and importance. By contrast, the Affordable Care Act (ACA) went through at least 44 public hearings, roundtables, and summits in the Senate HELP and Finance committees over the course of months, and the Senate HELP committee alone accepted more than 160 Republican amendments to the bill.

Similarly, progressives should not let the disastrous substance of the AHCA – which, according to the most recent estimates, would result in 24 million more people becoming uninsured – lower the bar for the Senate’s bill. It won’t be hard for the Senate to make a few minor changes and claim that they’ve improved the House’s bill. Instead, the Senate’s bill must be judged against the ACA, and whether it provides comparable coverage to a comparable number of people.

Much of the final controversy in the House revolved around the AHCA’s last-minute amendments that undermine protections for people with pre-existing conditions. Yet in the Senate, which might not keep that provision, Medicaid is quickly becoming the central wedge issue.

Earlier in the AHCA debate, several Republican senators took strong positions in defense of Medicaid expansion, which now covers more than 11 million newly eligible people. In a letter to Majority Leader Mitch McConnell, Sens. Rob Portman (R-OH), Shelley Moore Capito (R-WV), Cory Gardner (R-CO), and Lisa Murkowski (R-AK) wrote that they “will not support a plan that does not include stability for Medicaid expansion populations.” The AHCA proposed phasing out expansion over time by ending expansion-level funding for new enrollees in 2020.

However, some of that resistance appears to have been short-lived. Already this week, Sen. Portman has said that he’s fine with ending Medicaid expansion as long as the phase out of funding is delayed a couple of years longer than it is under the current AHCA.

Portman is characterizing such a delay as a “soft landing.” Yet his own home state Republican governor, John Kasich, has pushed back against this line of thinking in blunt terms. Kasich has argued that the AHCA’s approach to Medicaid expansion would lead to people “living in the emergency rooms again” and unable to consistently access the health care they need.

Regardless of how senators from Medicaid expansion states attempt to spin it, a vote to merely delay the end of expansion is still a vote to end it. Instead of keeping his promise to protect Ohioans’ coverage, Portman is quibbling over the expiration date. In a way, he appears poised to play the same role on Medicaid that Rep. Fred Upton did for pre-existing conditions in the House – first criticizing the provision as unacceptable, then endorsing a fig leaf “fix” that does little to actually address the problem.

Portman’s waffling on this issue is especially egregious given Ohio’s struggles with the opioid epidemic and his own advocacy on addressing the crisis. Medicaid plays an incredibly important role in combating the epidemic. For example, Medicaid pays for 50 percent of buprenorphine sold in Ohio to treat opioid addiction, while an estimated 151,000 people in Ohio with mental illness or substance abuse disorders are covered by Medicaid expansion. Looking specifically at opioid addiction, it’s been estimated that nationally, 222,000 people with opioid disorders would lose coverage if the ACA were repealed. With Ohio having one of the four highest drug overdose rates in the nation in 2015, rolling back Medicaid coverage would be a disaster for the state’s efforts to reduce opioid abuse.

Of course, the AHCA’s threats to Medicaid don’t stop at ending Medicaid expansion. The bill also proposes massive cuts to traditional Medicaid by imposing per capita caps. These would cap federal funding for Medicaid on a per-person basis, ending the traditional Medicaid guarantee as we know it and forcing states to make significant cuts in eligibility.

The non-partisan Congressional Budget Office estimated that these two AHCA proposals combined would cut $839 billion from Medicaid over 10 years and result in Medicaid covering 14 million fewer people. In addition, other beneficiaries could see their benefits reduced or costs increased as a result of the per capita caps.

In a breathtaking display of bad faith, House leaders and Trump administration officials have responded to criticisms of the AHCA’s Medicaid provisions by simply lying about them. For example, House Majority Leader Kevin McCarthy claimed shortly before the House vote that “nobody on Medicaid is going to be taken away,” while HHS Secretary Tom Price assured an incredulous Jake Tapper on CNN that cutting Medicaid funding by almost one-quarter would “absolutely not” lead to fewer people having Medicaid coverage.

Senate Republicans, on the other hand, are at least engaging with the Medicaid expansion issue. But some, like Portman, are already wavering – and worryingly, there’s been little sign so far that they are willing to defend Medicaid against per capita caps.

The Senate majority may try to rush this bill through without public debate, but they can’t outrun the fact that Medicaid is an essential lifeline for millions of Americans. If they merely tweak the AHCA’s harmful cuts to Medicaid, millions of their constituents will suffer.

Thomas Huelskoetter is a Policy Analyst with the Health Policy team at the Center for American Progress.