Does the Senate Health Care Plan Have ‘More Heart’? It Depends

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President Trump famously called the House plan to repeal and replace Obamacare “mean” — entreating Senate Republicans to make their version of the bill more generous.

Just hours before the Senate unveiled its draft legislation, he repeated that plea.

“I’ve been talking about a plan with more heart. I’ve said, ‘Add some money to it,'” Trump told a crowd in Iowa Wednesday night.

Now that the Senate’s plan is out, does it pass the White House test? Does it have more heart?

The short answer: a little. But it’s probably still mean.

If you’ve got preexisting conditions or rely on Obamacare’s health insurance subsidies, the Senate version of the legislation is certainly “nicer” — though still not as “nice” as Obamacare itself. On Medicaid, under the expansion? You’re ever so slightly better off than you would be under the House version of the bill, at least for a few years.

And if you’re one of the 59 million Americans who rely on traditional Medicaid, this legislation is actually significantly meaner.

The relative “meanness” of the legislation could still change — in either direction. Lawmakers said Thursday Senate Majority Leader Mitch McConnell of Kentucky is likely to make further changes as he works to convince reluctant members of his conference to back the plan ahead of an anticipated vote next Thursday. McConnell can spare just two Republican votes and still pass the measure, since no Democrat is expected to support it.

For now, several Senate Republicans are still evaluating whether the bill has gotten any nicer — and are quick to say it could yet change. Even the Senate health chairman, Lamar Alexander of Tennessee, demurred on the question after a Thursday briefing on the bill, saying he needed to read it more closely.

We took a look at the four of the major proposals from the Senate and whether they represent a softening of the House version of the legislation — or something meaner.

Changes to the health law’s subsidies

Senate Republicans have promised for months that they would make the tax credits included in the House’s health care measure more generous — and they have. The tax credits, like those in Obamacare, are aimed at helping people who don’t get health insurance through their job or a government program like Medicare or Medicaid afford a plan.

Obamacare’s tax credits were largely aimed at helping some of the poorest and oldest people in that category, which often meant that younger or wealthier people didn’t get as much financial help. House Republicans changed the way the subsidies are structured, to make more money available to younger and wealthier Americans, at the expense of the opposite group. They also included less money for the subsidies overall.

The Senate tempered that plan, returning to a subsidy structure nearly identical to the one laid out in Obamacare, though less generous. Beginning in 2020, the Senate version of the subsidies will focus more of the help on low-income people — including some of the people that Obamacare assumed would rely on Medicaid, in expansion states. People earning an annual salary of up to $47,550 this year could qualify for help under Obamacare; under the Senate plan that number drops to $41,580. For a family of four, Obamacare would have helped those earning up to $97,200; the Senate limits that amount to $85,050 this year.

There’s definitely more “heart” behind that move, especially for poorer or older Americans, or for those living in places with especially high health care costs. But the financial help remains less generous than the help available under current law.

Changes for people with preexisting conditions

An extremely controversial, last-minute amendment to the House-passed health care measure would have let states opt out of some of Obamacare’s most onerous health insurance requirements — including its rule that insurers charge everyone the same price for health insurance whether or not they suffer from a preexisting health condition. At least in some places, it could have returned some Americans to a time when insurers could jack up your insurance rates if they found out you were sick.

The Senate draft won’t let states waive that requirement — a much “nicer” measure for anyone with preexisting conditions.

But it will let states waive a whole host of other protections for Americans who don’t get their insurance through their job or a government program — like provisions that require insurance plans to cover certain benefits like care for people with autism or for new moms. People with preexisting conditions, then, might be able to get coverage — but depending on where they live, it might not actually cover services they need.

Whether it’s more or less nice, then, is up in the air — and probably depends on where you live.

Changes to Medicaid expansion

For states that expanded Medicaid, the Senate version of the package may be nicer than the House version — but only temporarily. Obamacare encouraged states to expand their Medicaid programs to adults with slightly higher annual incomes with an enticing offer of substantial federal funding. The House measure would essentially have cut off that extra funding abruptly in 2020.

The Senate draft instead begins winding down that extra funding in 2021, phasing it out more gradually over the following three years — at least in states that don’t end it sooner.

That’s a “nicer” path for the next few years, but, ultimately, it’s just as mean as before.

Changes to Medicaid

The “meanest” change to the Senate draft concerns the traditional Medicaid program, which provides health insurance for millions of low-income Americans. The House-passed package included huge, sweeping cuts to the federal funding for the program, worth a whopping $834 billion over the next 10 years. A nonpartisan analysis of the cuts found it would nix Medicaid coverage for some 14 million Americans.

Far from mitigating those cuts, the Senate version actually ramps them up more quickly, beginning in 2025. Researchers at the Urban Institute suggest the change would cut as much as an extra $63.7 billion from Medicaid in the year 2028 alone. That makes the draft decidedly “mean” for anyone relying on the program.

“States will have to fill this shortfall by raising taxes, cutting enrollment, reducing benefits, or reducing provider reimbursement — all of which are difficult choices,” Matthew Buettgens, a senior research associate at the Urban Institute, wrote.

Changes in funding for mental health and opioid addiction

The Senate came close to tempering one of the biggest criticisms levied against the White House and its support for the House-passed American Health Care Act: that it would be devastating to thousands in need of treatment for substance abuse, especially opioids.

The package passed by the House didn’t do much to address the opioid crisis, but it would put about $15 billion in funding toward expanding access to mental health services. That’s gone in the Senate version.

But what’s decidedly “mean” about this latest draft is a policy that’s absent from the measure. Two Republican senators from heavily impacted states — Rob Portman of Ohio and Shelley Moore Capito of West Virginia — pushed Senate leaders to include a staggering $4.5 billion for each of the next 10 years in funding to help people suffering from opioid addictions.

Instead, the package includes a $2 billion appropriation for 2018 alone — $43 billion less than the lawmakers had requested.

In the end, the Senate was never going to be able to deliver a measure that was a whole lot nicer, despite Trump’s pleas.

There’s a simple reason for that: making the package more generous requires more spending, and the congressional process Republicans are using limits how much they can spend. That process, reconciliation, requires their version of the legislation to generate as much budgetary savings as the House version did. That means their package can’t suddenly include tax credits that are 10 times more generous than the House bill, unless they cut other programs by trillions of dollars.

“It shows the bind Senate Republicans are in. The bill has to have the same amount of deficit reduction,” said Edwin Park, vice president for public policy at the Center on Budget and Policy Priorities, which has criticized the Republican plan. “Unless they’re changing the basic structure, you end up with the same results.”

Put simply, they’re boxed in. There’s no easy way to “add some money to it,” as Trump suggested.

Since the House plan was “mean,” the Senate plan is, too.

Lev Facher contributed reporting.