Senate Parliamentarian Challenges Key Provisions of Health Bill

The Senate Republican bill to dismantle the Affordable Care Act encountered huge new problems on Friday night after the Senate parliamentarian challenged key provisions that are needed to win conservative votes and to make the health bill workable.

The provisions appear to violate Senate rules, the parliamentarian said, giving Democrats grounds to challenge them as the Senate prepares for a battle next week over the future of the Affordable Care Act.

One provision questioned by the parliamentarian, Elizabeth MacDonough, and cherished by conservatives would cut off federal funds for Planned Parenthood for one year. Another would prohibit use of federal subsidies to buy insurance that includes coverage for abortions.

A third provision would penalize people who go without health insurance by requiring them to wait six months before their coverage could begin. Insurers would generally be required to impose the waiting period on people who lacked coverage for more than about two months in the prior year.

If formally challenged, the provisions could survive only with 60 votes, a near-impossibility in the partisan, narrowly divided Senate. The abortion-related provisions are important to many conservatives, not just in the Senate but also in the House.

And Democrats made clear they would seize on the findings. “The parliamentarian’s decision today proves once again that the process Republicans have undertaken to repeal the Affordable Care Act and throw 22 million Americans off of health insurance is a disaster,” said Senator Bernie Sanders, independent of Vermont.

Mr. Sanders, the ranking member of the Senate Budget Committee, disclosed the preliminary decisions by the parliamentarian.

The waiting period provision is fundamental to the working of the bill. Because the legislation would end the Affordable Care Act’s mandate that most Americans have health insurance, the waiting period was designed to ensure that people could not simply wait to get sick before they purchased a policy.

Senate Republican leaders plan to begin debate next week on repealing the Affordable Care Act, President Barack Obama’s signature domestic achievement, which has provided health insurance to roughly 20 million Americans.

At the moment, Republican leaders lack the votes to ensure passage of their bill to repeal and replace the law, and they are still modifying it in hopes of gaining support from uncommitted Republican senators. All Democrats are expected to oppose the repeal bill.

Under the procedure that Republicans are using to speed passage of the health care bill, senators can object to a provision if it does not change federal spending or revenue or if the budgetary effects are “merely incidental” to some policy objective. The parliamentarian serves as a sort of referee, determining whether specific provisions of the bill comply with Senate rules.

Don Stewart, a spokesman for the Senate majority leader, Mitch McConnell, Republican of Kentucky, emphasized that “this is guidance, not a ruling.” The parliamentarian “provided guidance,” and that guidance will help inform subsequent drafts of the legislation, he said, suggesting that the bill could be revised to answer her questions.

The Senate’s presiding officer usually follows advice from the parliamentarian. But the full Senate can vote to overturn those decisions.

The parliamentarian also objected to a narrowly written provision that would shift Medicaid costs from New York’s counties to its state government. This provision, tagged by opponents as the “Buffalo Bailout,” was included in a repeal bill passed by the House in May to secure the votes of Republican House members from upstate New York.

The Senate Democratic leader, Chuck Schumer of New York, suggested that other provisions written specifically for different states could also be at risk.

“This will greatly tie the majority leader’s hands as he tries to win over reluctant Republicans with state-specific provisions,” Mr. Schumer said. “We will challenge every one of them.”

Even before the parliamentarian’s blow, Trump administration officials and Republican leaders were struggling to win over moderate Republicans with a new infusion of money to help people who would lose Medicaid under the Senate health care bill.

Senators are set to return to the Capitol on Monday, and Republican leaders are eager to begin debate in the Senate on health care, perhaps as early as Tuesday. It is unclear they have the votes needed to start the debate, let alone to ensure passage of a bill to repeal and replace the health care law.

In their latest bid for agreement on a plan to undo the health care law, Senate Republicans are weighing a proposal to add funds, perhaps $200 billion, to the bill to help low-income people transition from Medicaid to private insurance. But Republican leaders must balance the interests of senators from states that expanded Medicaid under the Affordable Care Act with the goals of fiscal conservatives, who see the repeal bill as a once-in-a-generation opportunity to rein in the growth of one of the nation’s largest entitlement programs.

“You can only go so far, and then you lose votes on one side where we want to make reforms within Medicaid,” Senator Michael Rounds, Republican of South Dakota, said after a lengthy meeting this week with administration officials and other Republican senators. “And if you don’t go far enough, then you’ve got folks that are concerned that we’re making the changes too quick. So it’s that balancing act of trying to keep everybody on board and feeling comfortable.”

The Congressional Budget Office says the Senate repeal bill would cut projected federal Medicaid spending by more than $750 billion in the coming decade, leaving 15 million fewer people on Medicaid in 2026, compared with the enrollment expected under current law.

Those cuts have caused deep concern to Republican senators from states that expanded Medicaid under the Affordable Care Act, including Rob Portman of Ohio, Shelley Moore Capito of West Virginia and Lisa Murkowski of Alaska.

“I would like to do more to help people at the low end of the income scale afford private health insurance,” Mr. Portman said, noting that more than 700,000 people in his state had gained coverage through the expansion of Medicaid under the Affordable Care Act.

Ms. Capito, in a video message on Friday, said that many of her constituents had been hurt by the Affordable Care Act, but that “many West Virginians have benefited from our state’s decision to expand Medicaid” under the health law.

“I have said all along that we need to both repeal and replace Obamacare, and I’m not giving up on that goal,” she said. But, she added, “We aren’t there yet.”

Opponents of repeal, including consumer advocates and health care providers in every state, are keeping up the pressure on Republican senators.

AARP called on senators to vote against the procedural motion to begin debate, while the American Medical Association panned the repeal measure and an alternate Senate bill that would repeal the health law without providing a replacement.

“Recent revisions do not correct core elements that will lead to millions of Americans losing health insurance coverage with a resulting decline in both health status and outcomes,” Dr. James L. Madara, the association’s chief executive, wrote to Senate leaders on Friday. The Senate legislation, he said, would undermine state Medicaid programs and weaken the individual insurance market.

Save My Care, a group that is fighting the repeal effort, is targeting Ms. Capito, Ms. Murkowski and Senator Dean Heller, Republican of Nevada, with new television commercials urging them to vote against repealing the health law.

“Senator Capito promised to protect our health care,” one of the ads says. “Now Washington insiders are pressuring her to back down.”

On the flip side, Republican senators risk angering conservative supporters — as well as President Trump — if they stand in the way of the repeal effort, perhaps by opposing the procedural motion to begin debate that is planned for next week.

“I don’t know how you face the people who elected you when you don’t even vote to take up the bill,” Senator Ted Cruz, Republican of Texas, said on Fox News.

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